1906 


No.   14  IN  THE  PHYSICIANS'   AND  STUDENTS'  BEADY- 
REFERENCE  SERIES. 


DISEASES 


Lungs,  Heart,  and  Kidneys, 


N.  S.  DAVIS,  Jk.,  A.M.,  M.D., 

Professor  of  Principles  and  Practice  of  Medicine,  Chicago  Medical  College;    Physician  to 

Mercy  Hospital;    Member  of  the  American  Medical    Association,  Illinois    State 

Medical  Society,  Chicago  Medical  Society',  Chicago  Academy  of  Sciences, 

Illinois    State   Microscopical    Society;    Fellow   of    the   American 

Academy  of  Medicine;  Author  of  "Consumption:  How  to 

Prevent  lb  and  How  to  Live  with  it,"  etc. 


^^•m^.  ^u^  >^gesak^ 


Philadelphia  and  London: 

THE  F.  A.  DAVIS  CO.,  PUBLISHERS. 
1892. 


Entered  according  to  Act  of  Congress,  in  the  year  1892,  by 

THE  F.  A.  DAVIS  CO., 

In  the  Office  of  the  Librarian  of  Congress,  at  "Washington,  D.C.,  U.S.A. 


Philadelphia,  Pa.,  U.S.A.: 

The  Medical  Bulletin  Printing  Honse. 

1916  Cherry  Street. 


Library 

top 

PREFACE. 


This  volume  comprises  a  part  of  the  topics  lectured 
upon  by  me  for  several  3'ears  in  the  Chicago  Medical 
College.  They  hijve  been  elaborated  from  ni}^  lecture 
notes.  It  has  been  my  endeavor  to  describe  as  clearly, 
concisely,  and  fully  as  possible  the  subjects  of  this 
book.  I  have  avoided  controversial  topics,  and  may 
sometimes  have  erred  by  stating  positively  what  is 
ratlier  probably  than  positively  true.  I  have  tried  to 
make  the  subject  of  treatment  especially  full,  and  have 
endeavored  to  give  explicit  directions  as  to  the  time 
when  individual  drugs  should  be  used,  the  exact  indica- 
tions for  them,  and  their  mode  of  action  in  each  disease. 
In  order  to  prevent  repetitions  when  the  mode  of  action 
of  drugs  was  the  same  in  several  allied  diseases  this  fact 
is  stated,  and  the  details  of  action  must  be  learned  from 
the  description  of  the  first  of  the  allied  maladies. 

That  the  volume  might  not  outgrow  the  '•  Read}' 
Reference  Series  "  for  which  it  was  intended,  numerous 
foot-notes  and  tables  of  bibliography  have  not  been 
added  to  the  text. 

N.  S.  Davis,  Jr. 

65  Randolph  St.,  Chicago, 
October.  1892. 

(ui) 

62418S 


TABLE  OF  CONTENTS, 


SECTION  I. 
Diseases  of  the  Bronchi,  Lungs,  and  Pleura. 

DISEASES   OP    the    BRONCHI. 
CHAP.  PAGE 

I.     Asthma 3 

II.     Trachitis  and  Bronchitis 22 

Acnte 22 

Capillary 24 

Chronic 26 

III.  Bronchiectasis 57 

DISEASES   OF   THE   LUNGS. 

IV.  Emphysema 61 

V.     Atelectasis 67 

VI.     Haemorrhagic  infarction 70 

VII.     Hypostatic  and  passive  congestion 73 

VIII.     Pulmonary  oedema 78 

IX.     Catarrhal  pneumonia  , 82 

X.     Croupous  pneumonia 86 

XI.     Cirrhosis  of  the  lung 107 

XII.     Pulmonary  abscess  and  gangrene 112 

XIII.  Pulmonary  tuberculosis •    •    •  1^^ 

XIV.  Neoplasms  of  the  lungs 167 

DISEASES    OF    THE    PLEURA. 

XV.     Pleurisy 169 

Acute  fibrinous  or  dry  pleurisy 173 

Serous  pleurisy 176 

Empyema 177 

XVI.     Pneumothorax 187 

XVII.     Hydrothorax 194 

(V) 


vi  Table  of  Contents. 

SECTION  11. 

Diseases  op  the  Heart, 

diseases  of  the  pericardium. 

CHAP.  PAGE 

XVIII.     Pericarditis. 199 

XIX.     Hydrops  pericardii 207 

XX.     Pneumopericardium 208 

DISEASES    OP    THE    HEART-MUSCLE. 

XXI.     Dilatation  of  the  heart 210 

XXII.     Cardiac  hypertrophy 215 

XXIII.  Fatty  heart.    . 220 

XXIV.  Indurative  degeneration 22(5 

XXV.     Myocarditis 230 

Simple 230 

Purulent      230 

DISEASES    OF   THE   ENDOCARDIUM. 

XXVI.     Endocarditis 231 

XXVII.     Chronic  valvular  disease 239 

Aortic  insufficiency  .       243 

Stenosis  of  the  aortic  orifice 245 

Mitral  insufficiency 24(> 

Stenosis  of  the  mitral  valves 249 

Pulmonary  insufficiency  and  stenosis    .    .  250 

Tricusjiid  insufficiency 251 

DISEASES    OF    CARDIAC  INNERVATION. 

XXVIII.     Tachycardia,  or  nervous  palpitation 256 

SECTION  III. 


Diseases  of  the  Kidneys, 
functional  inactivity. 
XXIX.     Ursemia 


263 


diseases    of    renal    CIRCULATION. 

XXX.     Passive  congestion  of  the  kidneys  ......    274 


Table  of  Contents. 


Vll 


RENAL   INFLAMMATIONS. 
CHAP.  PAGE 

XXXI.  Acute  nephritis      279 

XXXII.  Chronic  parenchymatous  nephritis 295 

XXXIII.  Interstitial  nephritis 313 

XXXIV.  Suppurative  nephritis 333 

RENAL   DEGENERATION. 

XXXV.     Amyloid  kidney 337 

DISORDERS   OP   THE    RENAL   PELVIS. 

XXXVI.     Nephrolithiasis 342 

Hydronephrosis 345 

XXXVII.     Pyelitis 350 


SECTION 


Diseases  of  the  Bronchi,  Lungs, 
and  Pleura. 


1    A 


(1) 


DISEASES   OF  THE  BRONCHI, 


CHAPTER  I. 

Asthma. 

Nature. — Asthma  is  an  expiratory  dyspnoea  which 
occurs  parox3'sraall3-,  and  is  usually  sudden  in  its  onset. 
As  a  rule,  the  paroxysms  are,  at  longest,  of  only  a  few 
hours'  duration.  The  exact  nature  of  these  attacks  is 
unknowu.  Bj'  most  clinicians  they  are  believed  to  be 
due  to  spasmodic  contraction  of  the  bronchi,  which  is 
excited  through  the  agency  of  the  nervous  system.  A 
smaller  number  believe  that  the  narrowing  of  the 
bronchi  is  due  to  a  sudden  and  very  great  congestion 
of  their  mucous  membranes.  Such  a  congestion  could 
only  be  produced  through  the  active  agenc}'  of  the 
vasomotor  nervons  system.  It  may  be  likened  to  the 
cutaneous  congestion  and  swelling  of  hives.  Intense 
congestion  of  the  trachea  and  that  part  of  the  right 
bronchus  which  can  be  seen  in  a  laryngeal  mirror 
can  be  observed  during  an  attack  of  asthma.  A  still 
smaller  number  of  observers  explain  the  paroxysm 
upon  the  supposition  that  it  is  due  to  a  spasm  of  the 
diaphrngm,  which  causes  an  enlargement  of  the  thorax, 
and,  therefore,  sudden  dilatation  of  the  lungs  and  diflfi- 
cult  and  unnatural  respiration.  This  view  is  based  upon 
the  fact  that  in  many  cases  of  asthma  no  movement  of 
the  diaphragm  can  be  demonstrated.  There  are  other 
cases,  however,  in  which  movements  can  be  demon- 
strated. The  expianntion  is  not,  therefore,  of  univer- 
sal  applicabilit}'.     That    muscular   contx'action   of   the 

(3) 


4  Diseases  of  the  Bronchi. 

bronchi  can  be  produced  has  been  demonstrated  bj' 
physiologists.  The  suddenness  of  the  onset  of  these 
attacks,  and  often  of  their  cessation,  as  well  as  the 
prompt  relief  so  frequently  obtained  from  such  drugs 
as  chloroform  and  chloral,  demonstrates  the  dominant 
influence  of  the  nervous  S3'stem  in  their  production. 
Most,  if  not  all,  cases  of  asthma  are  of  reflex  origin. 
Therefore,  the  physiological  mechanisms  wliich  are  in- 
volved consist  of  (1)  a  source  of  irritation  or  sensitive 
nerve-endings  that  are  subject  to  irritation ;  (2)  the 
central  nervous  system  by  which  the  irritation  ex- 
perienced by  the  sensitive  nerves  is  reflected  to  the 
motor  ones ;  (3)  the  motor  nerves  and  muscular  fibres 
of  the  bronchi  which  constitute  the  focus  of  irritation. 
Undoubtedly  the  mucous  membranes  become  reddened 
simultaneoush'.  A  temporary  expansion  of  the  lung- 
alveoli  in  this  disease  is  the  result  of  overfilling,  because 
of  imperfect  emptying  during  expirntion.  The  calibre 
of  the  smaller  bronchi  is  diminished  ;  and,  as  inspira- 
tion, which  is  accomplished  purely  by  muscular  action, 
is  a  much  more  forceful  act  than  expiration,  which  is 
brought  about,  chiefl}'  b}'  the  elasticit}'  of  the  lung-tissue, 
the  weight  of  the  tlioracic  and  abdominal  walls,  and  in 
d3'spnoea  tlie  exercise  of  voluntary  muscles,  which  do 
not,  however,  act  under  the  most  advantageous  con- 
ditions, more  air  gradually  enters  tlie  alveoli  than  can 
be  forced  out.  This  temporary  expansion  of  the  lungs 
leads  to  an  enlargement  of  the  entire  thorax  during  the 
dyspnoeic  paroxj  sm. 

Symptoms. — The  asthmatic  attacks  usualh'  occur  in 
periods  lasting  from  a  few  days  to  several  weeks,  dur- 
ing wliicli  time  they  recur  at  regular,  and  usually  at 
dail}^,  intervals.  The  periods  ma^^  be  weeks  or  months 
apart.     Less  frequently  a  single  paroxj^sm  of  dyspnoea 


Asthma.  5 

will  occur  not  followed  by  others,  or  followed  by  them 
only  after  a  long  intermission. 

In  the  majority  of  cases  there  are  no  premonitory 
symptoms,  but  in  this  respect,  as  in  the  causation  of  the 
disease,  there  is  much  of  idiosyncrasy  in  each  case.  In  a 
proportion  of  them  there  are  premonitory  symptoms  that 
are  peculiar  to  each  individual.  A  person  is  occasion- 
ally found  whose  attacks  are  uniformly  preceded  by  an 
unnatural  drowsiness,  or  it  may  be  by  sneezing,  or  itchi- 
ness, or  flatulence,  or  b}'  the  i)assage  of  large  quantities  of 
very  pale  urine,  or  bj' various  other  symptoms  which  the 
sufferer's  experience  leads  him  to  recognize  as  warnings 
of  the  approach  of  an  attack. 

The  paroxysm  of  dyspnoea  almost  invariably  occurs 
in  the  earliest  morning  hours,  and  in  a  majority  of 
cases  between  two  and  four.  The  sufferer  usuall}'' 
awakes  from  a  sound  sleep  with  a  feeling  of  opi)ression 
in  breathing.  Almost  at  once  tiie  dyspnoea  becomes 
intense.  If  the  patient  is  not  accustomed  to  the  attacks 
relief  is  usually  sought  at  the  open  window  ;  those  who 
have  often  experienced  the  sufferings  of  asthma  assume 
at  once  some  favorite  attitude  which  they  have  learned 
makes  it  possible  for  them  to  breathe  with  tlie  most  ease. 
These  attitudes  are  various,  but  their  object  uniformly- 
is  to  fix  the  shoulders  rigidl}^  so  that  the  unusual 
muscles  of  respiration  which  find  origin  nbout  them  can 
act  most  advantageously  upon  the  thornx.  A  favorite 
position  with  many  is  a  sitting  one  upon  the  edge  of  the 
bed  or  upon  a  chair,  the  sides  of  which  are  grasped  b^' 
the  straightened  arms,  which  thus  hold  the  shoulders 
rigid.  The  body  is  bent  a  little  forward,  the  head  is 
thrown  back  to  straighten  the  neck,  and  the  mouth  is 
opened  to  permit  the  freest  ventilation  of  the  lungs. 
The   countenance  expresses  at  first  anxiety,  and  later 


6  Diseases  of  the  Bronchi. 

extreme  distress,  as  the  symptoms  of  suffocation  inten- 
sify. Tlie  vioieut  muscular  exertion  that  the  struggle 
for  breath  involves  produces  at  tiist  a  warm,  moist  per- 
spiration over  the  upper  part  of  the  bod}'  and  face.  As 
the  dyspnoea  is  prolonged  and  intensified  the  skin  be- 
comes cool  and  chimmy  ;  in  color  it  is  often  ashen  and 
the  lips  and  finger-nails  become  purplish.  In  a  word, 
marked  cyanosis  is  developed.  The  pulse  is  quick  and 
frequently  irregular,  small,  and  rigid.  The  veins  of  the 
neck  are  unusually  full  and  may  stand  out  like  whip- 
cords. This  is  due  to  the  interference  with  normal 
venous  circulation  by  the  change  in  intra-thoracic  press- 
ure caused  by  the  dyspnoeic  breathing.  The  bodil}' 
tem[)erature  is  rarely  abnormal. 

A  physical  examination  shows  that,  wdiile  the  respira- 
tory movements  are  so  labored,  they  are  no  more  or 
ver}^  little  more  rapid  than  normal.  The  thorax  is 
dilated,  and  it  retains  constantly  the  normal  inspiratory 
position.  Tiie  intercostal  spaces  do  not  change  in  width 
with  the  respiratory  moA'ements,  but  are  persistently 
stretched  to  their  widest  extent.  The  ribs  do  not 
move  freel}^  on  their  axes  with  each  respiration.  As 
the  chest  is  thus  constantly  extended  to  its  utmost,  in- 
spiration is  only  effected  b}' lifting  the  thorax  as  a  whole 
with  the  unusual  muscles  of  respiration.  The  inspi- 
rator}''  act  is  short  and  jerky  in  character  and  the  ex- 
pirator}'  is  ver^'  much  prolonged  and  labored.  During 
inspiration  the  lower  part  of  the  chest  will  be  observed, 
in  children,  not  to  be  expanded,  but  to  be  retracted. 
This  appearance  is  little  noticed  in  adults,  as  their  ribs 
are  too  rigid  to  be  thus  ])enr,  but  the  lower  intercostal 
spaces,  as  well  as  often  the  su})ra-clavicular  spaces,  are 
retracted  during  inspiration.  This  is  due  to  the  low 
pressure   within   the   thorax    during    inspiration.      The 


Asthma.  7 

air  is  not  able  to  enter  and  dilate  the  lungs  when  the 
thorax  is  lifted ;  therefore,  the  atmosphere's  weight 
presses  in  the  yielding  parts.  Palpation  usually  reveals 
no  change,  although  occnsionall}'  a  bronchial  fremitus 
can  be  felt.  Percussion  reveals  an  increased  resonance, 
whicli  is  uniform  upon  both  sides  of  the  chest.  The 
area  of  resonance  is  increased.  The  area  of  dullness 
over  the  heart  is  diminished  by  the  distension  of  the 
overlapping  portion  of  the  lung,  and  the  area  of  liver- 
dullness  is  depressed  and  seen  to  change  less  in  its 
horizon  with  inspiration  and  expiration  than  natural. 
These  changes  are  due  to  the  unusual  distension  of  the 
lungs  and  imperfect  respiration  maintained  b}'  them. 
The  apex-beat  of  the  heart  can  frequently  not  be  seen 
or  felt,  and  its  sounds  are  somewhat  distant  because  of 
the  overlapping  lung.  Auscultation  is  not  necessary  in 
order  to  hear  the  abnormal  respirator}^  sounds,  for  they 
are  so  loud  that  they  can  be  heard  many  feet  from  the 
sufterer.  If  the  ear  is  placed  on  the  chest,  vesicular 
sounds  will  be  found  entirely  absent,  and  only  piping 
and  crowing  will  be  audible,  and  the  latter  can  be  heard 
as  readily  b}'  the  by-stander.  The  inspiratory  sound  is 
very  short,  the  expiratory  much  prolonged. 

Usuall}'  wheu  the  dj-spnoea  is  most  intense,  the  cya- 
nosis most  marked,  and  fatal  suffocation  appnrently 
imminent,  relief  comes  and  the  oppression  rapidly 
abates.  With  or  ver}"  shortly  preceding  this  abate- 
ment a  slight  cough  begins.  In  many  cases  it  is  so 
slight  as  to  be  unnoticed.  Usuall}^  it  is  accompanied 
by  the  expectoration  of  a  small  nuuiber  of  sputa-chunks, 
of  small  size  and  glary,  gra}',  adhesive  character.  If 
the  sputa  is  examined  microscopicMlI}'  it  is  found,  in  a 
large  proportion  of  cases,  to  contain  cliaracteristic  ele- 
ments.    The  most  striking  are  spiral  coils  of  thread- 


8  Diseases  of  the  Bi'onchi. 

like  fibrils.  The}'  ure  not  strictl}'  peculiar  to  iistlima, 
although  they  occur  witli  it  more  uniformly  than  with 
any  other  disease.  They  have  been  noticed  in  the  sputa 
of  capillary  bronchitis  and  rarely  in  that  of  croupous 
pneumonia  and  phthisis.  The  needle-like  crystals  of 
Charcot  can  also  be  frequently  observed.  The  cellular 
elements  are  those  usual  to  sputa,  and  are  not  peculiar 
to  the  disease. 

The  paroxysm  that  I  have  described  typifies  those 
of  the  severest  t3'pe  of  the  disease.  Ever}'  grade  of 
milder  form  can  be  observed,  even  to  that  in  which 
there  is  little  disturbance  of  respiration  more  than  a 
feeling  of  oppression.  The  duration  of  the  paroxj'sm 
of  d3'spnoea  is  variable.  It  may  last  a  few  minutes 
only, — usuall}'  it  persists  for  from  one  to  three  hours. 
In  rarer  cases  it  will  last  for  several  da3S  with  little 
change,  except  an  intensification  during  the  night. 
These  are  nsuall}'  cases  in  which  bronchitis  is  present, 
and  is  the  exciting  cause  of  the  asthma.  Such  cases 
are  accompanied  by  more  or  less  persistent  cough  and 
somewhat  accelerated  breathing.  They  can  be  dis- 
tinguished from  capillar}-  bronchitis  with  difficulty, 
except  b}^  the  parox3'smal  character  of  the  dyspnoea 
and  by  the  absence  of  fever. 

The  intervals  between  attacks  of  frankh'-spasmodic 
asthma  are  passed  b}'  the  patient  in  perfect  comfort. 
When  the  dyspnoea  first  ceases  the  suflferer  is  so  ex- 
hausted by  the  preceding  laborious  breathing  that 
.nlmost  invariably  he  drops  upon. the  bed  and  falls  into 
a  quiet  and  sometimes  protracted  sleep.  Ou  awakening 
from  this  sleep  the  patient  usuall}-  feels  perfectly  com- 
fortable. At  tliis  time  an  examination  will  reveal  no 
abnormal  physical  signs.  In  most  instances  the  dyspnoea 
will  recur  the  following  night,  and  ma}'  for  several  more. 


Asthma.  9 

Diagnosis. — Diagnosis  is  usually  not  difficult ;  the 
sudden  onset,  the  severity  of  the  d^^spnoea,  the  sudden 
cessation,  the  complete  restoration  dnring  the  intervals, 
and  repetition  of  the  attacks  are  characteristic.  It  is 
necessar}^  at  times,  to  distinguish  the  dyspnoea  of  spas- 
modic asthma  from  that  produced  by  laryngeal  or 
tracheal  obstruction.  In  the  latter  cases  the  dyspnoea 
is  mainly  inspiratory^  while  in  asthma  it  is  expiratory. 
Upon  search  a  cause  for  the  dyspnoea  is  found  in  the 
upper  air-passages.  The  noise  of  respiration  is  loudest 
about  the  throat. 

From  capilhiry  bronchitis  we  can  differentiate  spas- 
modic asthma:  1.  By  the  mode  of  onset,  which,  in  the 
former,  is  somewhat  slow  and  gradual,  not  sudden.  2. 
By  the  absence  of  fever  in  asthma.  It  must  be  remem- 
bered, however,  tliat  an  apyretic  capillar}'  bronchitis 
occurs  at  times.  3.  Bv  the  hurried  respiration  of  the 
bronchitis.  4.  By  the  presence  of  cough.  5.  By  the 
sudden  cessation  of  the  d3'spnoea  of  asthma  and  more 
persistent  character  of  that  of  the  inflammator}'  atfec- 
tion.  From  emphysema  it  is  to  be  distinguished  (1) 
by  the  chronicity  of  the  d\'spnoea,  (2)  by  its  lack  of 
paroxj^smal  character,  and  (3)  by  the  permanent  dis- 
tension of  the  chest  in  the  former.  From  cardiac 
asthma  (1)  b}^  the  existence  of  a  cardiac  lesion  that 
will  explain  its  cause,  (2)  by  its  persistence,  and  (3) 
by  the  absence  of  a  history  of  attacks  prior  to  the 
development  of  the  cardiac  trouble. 

It  must  be  remembered  that  bronchitis,  emphj'sema, 
and  cardiac  disease  may  be  complicated  by  true  spas- 
modic asthma.  In  all  cases  of  persistent  d3'spnoea  with 
niglitl}'  exacerbations,  some  other  cause  than  simply 
spasm  of  the  bronchi  may  be  quite  confidentl}^  sus- 
pected, even  if  it  cannot  be  proven. 


10  Diseases  of  the  Bronchi. 

Causes. — The  causes  of  asthma  are  both  predispos- 
ing and  exciting.  There  are  a  few  cases,  the  cause  of 
which  is  unknown,  that  are  often  described  as  idio- 
pathic. This  group  is  constantly  growing  smaller  as 
our  knowledge  of  the  causes  of  the  disease  increases, 
(a)  Age,  to  a  limited  extent,  predis[)Oses  to  the  disease, 
since  it  occurs  most  frequentl}'  between  the  ages  of  20 
and  40.  (b)  It  is  said  to  occur  oftener  in  males  than  in 
females,  (c)  Most  asthmatics  are  nervous  by  tempera- 
ment. It  is  frequently  noticed  that  the  disease  attacks 
some  members  of  several  generations  of  the  same 
family,  and,  therefore,  it  is  regarded  as  (d)  inheritable, 
(e)  Such  diseases  as  scrofula,  heart  diseases,  Bright's 
diseases,  gout,  and  rheumatism  are  very  frequentl}'  asso- 
ciated with  asthma,  and  are  regarded  as  predisposing 
to  it. 

The  exciting  causes  are  numerous,  and  \ixvy  with 
the  source  of  irritation,  whence  reflexly  the  bronchial 
spasm  is  produced.  The  most  usual  sources  of  irrita- 
tion are  in  the  nose,  bronchi,  pharynx,  stomach,  and 
womb. 

Acute  and  chronic  nasal  catarrh,  and  especiall}-  nasal 
polj'pi,  are  common  causes.  Spasmodic  asthma  is  of 
very  frequent  occurrence  in  connection  with  the  coryza 
of  hay-  and  rose-  fever,  which  is  generall}'  supposed  to 
be  produced  by  a  vegetable  dust  peculiarly  irritating  to 
certain  individuals. 

Bronchitis  is  occasionallj-  accompanied  b}'  asthma. 
Whether  in  these  cases  the  asthma  arises  from  a  reflex 
irritation  of  the  motor  bronchial  nerves  or  from  direct 
irritation  of  them  b}'  the  surrounding  inflamed  tissue  it 
is  impossible  now  to  say.  As  drugs  which  benumb  the 
central  nervous  S3'stem  do  good  in  these  as  in  other 
cases  of  asthma,  it  scarcely'  seems  probable  that  direct 


Asthma.  11 

irritation  of  the  motor  nerves  can  be  the  cause  of  the 
spasm.  Still  more  rarely  enhirged  tonsils  and  pharjm- 
geal  and  laryngeal  growths  are  the  source  of  irritation 
of  tlie  disease. 

Irritation  of  the  stomach  ver3'  rarely  is  the  exciting 
cause  of  astlima.  lu  a  ver}-  small  proportion  of  cases 
we  find  disease  of  tiie  womb  or  pregnane}^  the  source 
of  the  irritation  thnt  produces  the  bronchial  spasm. 

Compression  of  tiie  main  trunk  of  the  pneumogastric 
b}'  tumors,  or  their  iuvolvement  in  such  growth,  has  a 
few  times  been  observed  to  be  causative  of  the  disease. 
Assertions  that  asthma  ma}^  result  from  lesions  of  the 
central  nervous  system  have  not  been  authoritatively 
confirmed. 

It  is  more  than  probable  that  cardiac  disease  and 
Bright's  diseases  do  not  simply  predispose  to  asthma, 
but  in  the  course  of  these  disorders  there  is  produced 
some  substance  which,  when  carried  to  the  nervous  S3'S- 
tem  b}'  the  blood,  proves  an  exciting  cause.  The  fre- 
quent occurrence  in  Blight's  diseases  of  asthma,  associ- 
ated with  other  symptoms  of  mild  ursemic  poisoning,  has 
led  to  a  general  belief  that  it  is  also  due  to  uraemia. 

Rarel}',  examples  of  a  peculiar  form  of  asthma  are 
seen  in  wdiich  the  source  of  irritation  seems  to  be  mental 
or  central  rather  than  peripheral.  I  refer  to  those  cases 
in  which  the  dyspnoea  is  caused  b}'  fear,  and  to  those  in 
which  it  is  excited  by  certain,  although  the  most  varied, 
localities  or  odors.  If  tliese  susceptible  persons  are  not 
conscious  of  being  in  the  locality  of  the  noxious  object, 
no  respiratory  discomfort  is  experienced.  These  are 
cases  of  mental  idios3'ncras3',  and  usually  are  associated 
with  an  hysterical  temperament. 

Treatment. — Prophylaxis  can  be  applied  to  a  large 
number  and  variety  of  cases.     Exemption  from  the  dis- 


12  Diseases  of  the  Bronchi. 

ease  is  oiil}^  obtainable  by  either  removing  the  cause  of 
the  disease  from  the  siitlerer  or  removing  the  sufierer 
from  the  cause.  The  latter  method  is  especially  appli- 
cable to  the  cases  of  liny  fever  in  which  foreign  bodies 
in  the  atmosphere  are  the  exciting  cause  and  the  nasal 
mucous  membrane  the  source  of  irritation  of  the  dis- 
ease and  complicating  asthma.  A  change  of  climate 
and,  therefore,  of  air  is  curative.  The  localities  in  this 
countr}^  that  afford  most  perfect  exemption  are  the 
White  Mountains,  Mackinac,  many  localities  along  the 
shore  of  Lake  Superior,  and  numerous  places  in  the 
more  elevated  parts  of  the  Rocky  and  other  mountain- 
ous regions.  A  residence  in  the  heart  of  a  thickly-pop- 
ulated city  will  often  grant  to  individual  cases  immunit}', 
although  they  ma}'  suffer  severel}-  in  neighboring  sub- 
urbs. As  tliese  attacks  are  most  likely  to  occur  at  cer- 
tain seasons,  especially  in  August  and  September,  and 
less  frequentlv  in  June,  temporary  clianges  of  abode  at 
these  times  will  usually  give  exemption  to  those  who  are 
liable  to  the  attacks.  Manj-  of  the  afflicted  cannot  take 
advantage  of  such  prophylactic  treatment. 

To  prevent  asthmas  that  result  from  the  existence 
of  chronic  inflammation  or  tumors  within  the  nostrils,  a 
destruction  of  the  irritating  tissue  must  be  effected.  A 
temporary  relief  can  often  be  obtained  b}'  the  use  of 
local  anaesthetics.  Rarel}',  the  source  of  irritation  is 
found  in  the  pharynx  or  larynx.  In  such  cases  the 
irritant  is  usually  a  morbid  growth  or  a  chronic  inflam- 
mation with  hypertrophy.  Such  lesions  must  be  treated 
just  as  are  their  analogues  in  the  nasal  cavit}'. 

The  indications  for  treatment  are  (a)  to  prevent  the 
development  of  dyspnoea  and  {b)  to  relieve  the  dyspnoea 
when  developed.  In  the  intervals  between  the  dyspnoeic 
attacks  the  iodides  are  often   prescribed,  with  marked 


Asthma.  13 

benefit.  TJnfortunatel}' ,  they  do  not  uniformly  ward  off 
or  mitigate  the  paroxysms.  The  cases  in  which  good 
results  are  most  uniformly  obtained  from  tlieir  employ- 
ment complicate  chronic  bronchitis.  It  is  probable  that 
their  good  effects  are  largely  due  to  the  property,  which 
they  possess,  of  promoting  re-absorption  of  cellular 
exudates  in  inflamed  tissues.  The  iodide  of  soda  is  the 
most  eligible  preparation  for  persistent  employment.  It 
should  be  given  for  weeks,  and  often  for  months.  1 
have  seen  several  cases  apparently  exempted  from 
severe  attacks  1)3'  senecio  aureus.  The  drug  was  not 
given  during  dyspnoea,  but  while  the  parox3sms  were 
threatening,  and  at  a  season  when  the  patients  were 
usually-  afflicted  by  them.  By  the  continued  use  of  it 
for  several  weeks  an  actual  outbreak  was  avoided. 

An  analysis  of  the  mode  of  action  of  the  drugs  that 
are  most  successful  in  asthma  shows  that  in  one  of  three 
ways  thev  relieve  the  spasm.  We  may,  therefore,  place 
them  in  three  groups.  The  first  includes  those  that 
affect  the  source  of  irritation,  the  second  those  that 
benumb  the  neive-centie  or  reflector  of  irritation,  and 
the  third  those  that  act  upon  the  focus  of  irritation. 

In  the  first  group  we  must  place  a  very  promiscuous 
collection  of  drugs,  since  the  source  of  irritation  may 
be  in  almost  any  part  of  the  body.  We  find,  therefore, 
in  this  list,  those  medicines  thnt  alia}'  irritabilit}'  of 
nasal,  phar3'ngeal,  bronchial,  and  gastric  mucous  mem- 
branes, and  also  those  that  allay  irritability  of  the  womb 
and  some  of  the  parench3'matous  organs. 

In  asthma  of  nasal  origin  there  is  necessary  for  its 
production  not  ouIn'  the  specific  irritant  in  the  atmos- 
phere, but  a  peculiar  sensitiveness  of  the  nerve-endings 
which  constitute  the  source  of  irritation,  and  possibly, 
also,  of  the  nerve-centres.     Advantage  can  be  taken  of 


14  Diseases  of  the  Bronchi. 

these  facts  in  mitigating  and  preventing  the  disease 
when  a  change  to  a  pnre,  nnirritating  air  is  impossible. 
Thus,  in  ha}'  fever,  local  anesthetics  api)lied  to  the 
nasal  mucous  membrane  Avill  frequentl}' hold  the  disease 
in  abeyance,  or  at  least  mitigate  it.  Of  the  remedial 
agents  that  can  be  topically  applied  for  anaesthetic 
effects,  cocaine  is  the  most  important.  A  5-  to  10-  per- 
cent, solution  may  be  sprayed  into  the  nose  through 
the  anterior  nares,  and,  when  necessary-,  also  applied  to 
the  posterior  nares  through  the  mouth.  Or  it  can  be 
employed  by  insufflating  a  powder  composed  of  it  and 
some  bland  diluent.  A  cocaine  ointment  ma}'  be  used, 
a  little  being  placed  in  the  nostrils  and  allowed  to  melt 
and  trickle  backward,  so  as  to  anoint  the  mucous  sur- 
faces. This  method  is  less  efficacious  than  either  of  the 
others,  since  the  drug  is  not  applied  so  uniforml}^  to  all 
parts  of  the  nose.  It  must  be  remembered,  in  regard  to 
cocaine,  that,  if  used  in  small  amounts  often,  or  in 
strong  solution  less  frequently,  symptoms  of  intoxica- 
tion ma}'  be  produced.  I  have  rarely  found  it  necessary 
to  use  preparations  of  more"  than  4-per-cent.  strength. 
Often  a  few  applications  of  cocaine  will  greatly  aid  in 
discovering  the  source  of  irritation,  for  cases  occur  in 
which  we  suspect  the  source  to  be  in  the  nose  or  throat, 
and,  if  applications  to  these  parts  allay  the  dyspnoea,  we 
may  feel  that  our  suspicions  are  well  founded. 

As  a  topical  application  morphia  is  also  useful.  It 
acts  less  promptly  than  cocaine,  but  often  its  effects  arc- 
more  lasting.  A  good  formula  consists  of  4  per  cent. 
of  cocaine  and  2  per  cent,  of  morphia,  mixed  with 
some  inert  powder  or  with  water,  according  as  one 
wishes  to  make  applications  by  insufflating  or  by 
spraying. 

We  must  place  in  this  miscellaneous  group,  also,  the 


Asthma.  15 

various  expectorant  and  anodyne  mixtures  that  are 
emplo^'ed  to  allay  laryngitis,  trachitis,  or  bronchitis, 
since  these  inflanmiations  are  frequent  causes  of  asthma, 
and,  therefore,  their  cui'e  will  give  exem[)tion.  The 
efficacy  of  such  mixtures  is  greatly  enhanced  by  com- 
bining with  tiiem  drugs  that  belong  to  the  second  group, 
or  those  that  allay  the  excitabilit}*  of  the  reflex  centres. 

In  the  same  way,  asthma  which  accompanies  un- 
compensated valvular  disease  of  the  heart  is  relieved 
b}^  digitalis  and  similar  drugs.  They  strengthen  the 
heart's  action  and  give  greater  tone  to  the  blood- 
vessels, and  thus  reduce  venous  hyperaemia  of  the 
lungs  and  bronchi.  These  remedies  accomplish  more 
for  such  asthmatics  than  those  that  relax  muscular 
spasm.  They  do  good  by  stopping  the  irritation  at  its 
source.  Cases  in  which  the  source  of  irritation  is  in 
the  organs  of  the  alimentary  tract  are  relieved,  and 
often  permanently'  cured,  by  treatment  of  the  primary 
lesions.  Occasional!}^,  a  woman  is  found  who  is  persist- 
ently troubled  with  asthma  during  pregnancy,  although 
free  from  it  at  other  times.  Absolute  relief  is,  so  long 
as  pregnane}'  lasts,  usually  impossible.  I  have,  how- 
ever, seen  marked  benefit  obtained  by  the  persistent  use 
of  viburnum  prunifolium.  This  drug  without  doubt 
lessens  the  irritability  of  the  uterine  tissues,  and  thus 
diminishes  the  irritabilit}^  of  the  source  of  irritation  of 
the  asthma. 

The  second  group  of  drugs  includes  those  that  act 
on  the  nerve-centres,  and  thus  inhibit  reflex  action. 
The  most  important  of  them  are  chloral,  chloroform, 
ether,  opiates,  and  bromides.  When  dyspnoea  is  intense 
a  few  whiffs  of  chloroform  will  give  relief  promptl3\ 
As  the  relief  is  often  not  of  long  duration,  and  as  the 
drug  cannot  with   safet}^  be    left  in   the  hands   of   the 


16  Diseases  of  the  Bronchi. 

sufferer,  its  niiige  of  usefulness  is  limited.  Of  this 
group,  chloral  is  the  safest  and  most  universally  useful. 
If  the  asthma  is  wholly  parox3'snial,  it  is  best  adminis- 
tered in  one  or  two  full  doses  rather  than  in  several 
smaller  ones.  Often  1.0  to  1.5  grammes  (15  to  20 
grains),  given  in  sweetened  water,  will  not  only  relieve 
present  d3'spnoea,  but  produce  an  effect  sufticientlj'  last- 
ing to  suppress  the  attack.  In  cases  tliat  complicate 
bronchitis,  trachitis,  or  laryngitis,  and  in  which  the 
dyspnoea  is  not  paroxysmal  onh%  but  to  some  extent  is 
persistent,  since  the  source  of  irritation  is  constanth' 
excited,  the  best  effects  are  obtained  by  the  repetition 
of  smaller  doses  of  chloral,  bromides,  opiates,  or  of 
mixtures  of  all  these  with  expectorants.  In  this  wa}' 
the  nerve-centres  are  constantly  inhibited  or  restrained 
in  their  activity,  so  that  the  paroxysms  of  exacerbation 
are  held  in  abeyance,  and  time  is  gained  in  which  to 
overcome  the  primary  inflammation.  A  formula  that 
I  have  frequentl}'  employed,  with  marked  benefit  in  such 
cases,  is  the  following: — 

R   Chloral., grms.  15.00  (,^iv). 

Ammonii  muriatis,  ..."  10.00  (5iiss). 

Morphiae  muriatis,  .         .         .     grm.  0.20  (gr.  iij). 

Antim.  et  pot,  tart.,       ..."  0.15  (gr.  iiss). 

Ex.  grindeliae  robustatse  fl.,  c.cm.  45.00  vel  60.00  (^iss). 

Aq.  vel  syr.  glycyrrhlz.,      q.  s.  ad     c.cm.  120.00  (^iv). 

Sig.  :  Give  one  teaspoonful  every  three  to  six  hours,  in 
sweetened  water. 

Morphia  and  the  bromides  are  less  generally  useful 
than  chloral.  The  bromides,  given  steadilj',  in  rather 
large  doses,  are  serviceable  when  the  source  of  irritation 
is  the  larynx  or  phar3'nx,  for  they  not  oul}^  act  favorabl}' 
by  lessening  the  excitability  of  reflex  centres,  but  also 
have   the   peculiar   propert}^   of  benumbing  the    nerve- 


Asthma.  IT 

endings  in  the  mucous  membrane  of  the  larynx  and 
phar3^nx.  The  dose  should  be  large;  for  example,  1.5 
to  3.0  grammes  (20  to  45  grains)  of  the  bromide  of 
sodium. 

There  is  another  class  of  remedial  agents  which  it 
is  difficult  to  classify  with  certainty,  for  our  knowledge 
of  their  ph3siological  action  is  imperfect,  and  the  results 
of  researches  are  not  completely  harmonious.  The 
drugs  to  which  I  refer  are  grindelia  robusta,  senecio 
aureus,  quebracho,  lobelia,  and  tobacco.  It  seems 
probable,  however,  that  as  remedies  for  asthma  they  can 
be  placed  in  this  second  group.  Death  from  tobacco 
poisoning  is  due  to  paralysis  of  respiration.  The 
physiological  action  of  lobelia  is  very  similar  to  that  of 
tobacco.  When  lobelia  is  used  in  asthma  it  must  be 
given  in  doses  of  from  2  to  4  cubic  centimetres  (^  to  1 
drachm)  of  the  tincture,  and  repeated  every  two  hours, 
or  oftener,  until  vomiting  and  relief  are  produced. 
Mitigation  of  the  d3'spnoea  usually  corresponds  with 
intense  nausea,  and  is  greatest  after  vomiting. 

Quebracho  has  a  peculiar  effect  upon  respiration  in 
healthy  persons.  It  slows  it  and  prevents  panting  when 
hurried  movements  are  made.  At  the  same  time  it  re- 
tards the  heart.  Gutman  has  shown  that  its  active 
principle,  aspidospermine,  produces  death  by  poisoning 
the  respiratory  centre. 

We  know  less  of  the  physiological  action  of  grinde- 
lia and  nothing  of  senecio.  Grindelia  produces  death 
only  in  very  large  doses,  and  then  by  paralyzing  respira- 
tion. In  smaller  doses  it  slows  the  respiration  and  the 
heart. 

The  effects  of  lobelia  must  be  carefully  watched,  for 
large  doses  have  produced  alarming  s^^mptoms.  For 
this   reason  I  have  employed  it  rarely,  but  grindelia  I 


18  'Diseases  of  the  Bronchi. 

have  administered  frequently,  and  quebracho  and  sene- 
cio  less  frequenth',  although  enough  to  feel  confident 
that  to  some  extent  the}'  are  useful.  The}'  are  so  much 
less  efficacious  than  some  other  remedies  at  our  com- 
mand for  the  relief  of  the  dyspnoea  that  I  rely  upon 
them  not  at  all  for  its  treatment,  but  rather  as  adjuvants 
for  warding  off  the  recurrence  of  the  paroxysms. 

Grindelia  and  quebracho  are  probabl}'  mildl}'  expec- 
torant, and,  through  their  bitterness,  tonic,  to  the 
stomach.  But  their  bitter  and  otherwise  unpleasant 
taste  limits  greatl}'  their  eligibilit}'.  Their  fluid  ex- 
tracts can  be  administered  in  doses  of  2  to  4  cubic  centi- 
metres {\  to  1  drachm). 

The  third  group  of  drugs  embraces  the  nitrites  and 
nitro-glycerin.  Amyl  nitrite  administered  by  inhala- 
tion has  been  used  in  asthma  for  a  number  of  years. 
Nitro-glj'cerin  has  been  used  less  frequently,  and  the 
nitrites  of  soda  and  potash  still  less.  Prof.  Fraser,  of 
Edinburgh,  has  given  us  the  most  trustworthy^  informa- 
tion as  to  the  relative  value  of  these  drugs  in  asthma. 
The}^  all  relieve  the  spasm,  and  with  wonderful  prompt- 
ness. The  effects  of  am}-!  nitrite  are  ver}^  transitory. 
Nitro-gl3'cerin,  when  given  in  doses  of  sufficient  size,  is 
apt  to  provoke  congestive  headache.  The  nitrite  of 
soda  he  found  gave  quite  as  prompt  relief  as  the  others, 
was  less  likel}'  to  provoke  headache,  and  produced  more 
enduring  effects.  The  more  purely  spasmodic  the  case, 
the  more  efficacious  are  these  drugs.  Dr.  Fraser  found 
that,  in  two  or  three  minutes  after  the  administration  of 
even  half-grain  doses  of  the  nitrite  of  soda,  marked  re- 
lief was  noticeable  in  the  patient's  breathing  and  a  less- 
ening of  the  crowing  and  piping  in  the  chest.  In  ten 
minutes  or  less,  patients  feel  comfortable.  It  was  rare 
that  it  was  necessar}^  to  repeat  the  dose  in  any  single 


Asthma.  1& 

attack.  The  good  effect  of  these  drugs,  when  admin- 
istered in  the  usual  therapeutic  doses,  is  undoubtedh' 
chiefly  due  to  their  action  upon  the  muscle-fibres  of  the 
bronchial  tubes,  irritability  of  which  they  lessen  or 
temporarily  destroy.  In  other  words,  they  act  upon  the 
focus  of  irritation.  In  less  degree  they  ma^^  diminish 
the  irritabilit}^  of  the  motor  nerves.  This  is  a  some- 
what doubtful  effect  of  therapeutic  doses,  although  it 
can  be  obtained  from  large  doses.  In  using  the  nitrite 
of  soda,  which,  from  considerable  personal  experience, 
I  can  commend,  it  must  be  remembered  that  there  are 
two  preparations  in  the  market, — a  "commercial"  and  a 
chemically  pure.  The  former  can  be  given  in  doses  of 
from  0.3  to  0.6  gramme  (5  to  10  grains),  and  1.3  grammes 
(20  grains)  have  been  given  without  harm.*  The 
therapeutic  dose  of  the  chemically-pure  drug  is  from 
0.06  to  0.3  gramme  (1  to  5  grains).  While  the  most 
beneficial  effects  are  obtained  in  the  most  frankly 
paroxysmal  cases,  marked  benefit  may  be  derived  from 
the  continued  use  of  these  remedies  in  asthma  that  com- 
plicates bronchitis  and  that  is  to  some  extent  persistent. 
In  such  cases  I  have  combined  the  nitrite  of  soda  with 
the  usual  expectorant  and  anodyne  treatment  of  bron- 
chitis. It  may  be  administered  in  18-  to  30-centigramme 
doses  (3  to  5  grains)  every  three  to  six  hours. 

Atropia,  stramonium,  and  h3'0scyamus  constitute  an- 
other series  of  drugs  that  are  analgesic  to  the  focus  of 
irritation.  The  two  first  are  the  ones  most  frequently 
used  in  this  disease.  They  cause  relaxation  of  the  bron- 
chioles, in  part  by  benumbing  their  involuntar}'  muscu- 
lar fibres  and  in  part  by  lessening  the  sensibilit}"  of  their 
terminal  nerve-fibres.  While  efficient  in  aiding  to  give 
relief,  their  side-effects  are  so  marked  and  often  so  disa- 
*  Therapeutics :  its  Principles  and  Practice.    By  H.  C.  Wood. 


20  Diseases  of  the  Bronchi. 

greeable  that  thev  cannot  be  used  in  efficient  doses. 
The  action  of  tlie  drugs  is  so  well  known  that  I  need 
hardly  say  that  these  side-eftects  are :  dryness  of  the 
mouth  and  throat,  heat  and  redness  of  the  skin,  dil- 
atation of  the  pupil,  disturbed  vision,  and,  in  ver}"  sus- 
ceptible patients,  mental  perturbations.  Full  doses  are 
rarely  emploj^ed,  but  frequentl}'  small  doses  are  used 
to  re-inforce  the  action  of  other  drugs,  as  in  the  follow- 
ing formula,  which  is  especially  efficient  for  the  relief 
of  asthmatic  dyspnoea: — 

B  Chloral.,  ....  grms.  20  (3v). 
Sodii  nitritis,  .  .  .  grms.  3  (,^j). 
Tinct.  stramonii,  .         .     c.cm.     6  (3iss). 

Elix.  simpl.,         .      q.  s.  ad     c.cm.  60  (5ij). 
Sig. :  Take  one  teaspoonful  every  four  hours,  in  water. 

Not  onl}'  do  these  remedies  act  favorably  when  they 
are  taken  by  the  stomach,  but  the  inhalation  of  the  smoke 
of  the  crude  drugs  is  often  of  the  greatest  benefit.  Stra- 
monium-leaves are  used  in  this  wa}'  most  frequently. 
The  leaves  are  smoked  either  when  rolled  into  cigarettes 
or  from  a  pipe.  Their  efficacy  is  enhanced  b}-^  first 
soaking  them  in  a  saturated  solution  of  nitre  and  sub- 
sequentl}^  drying  them  for  use  ;  or  the}^  maj'  be  mixed 
with  or  rolled  in  bibulous  paper  that  has  been  thus  satu- 
rated. The  nitre  is  decomposed  by  the  heat,  and  a 
nitrite  is  formed  which  aids  in  relieving  the  dj-spnoea. 
There  are  numerous  proprietary  cigarettes  and  pastels 
for  asthma,  the  basis  of  whose  composition  is  stramonium 
and  nitre. 

When  uraemia  is  the  cause  of  asthma,  diaphoretics, 
diuretics,  and  cathartics  are  indicated  for  the  elimina- 
tion of  the  poison.  The  first  of  these  classes  of  drugs 
gives  the  most  prompt  relief.  Of  diaphoretics,  pilo- 
carpine administered  subcutaneously,is  the  most  prompt 


Asthma.  21 

in  its  action.  It  is  necessary  to  prevent  the  re-accumu- 
lation of  poisons  thus  eliminated.  This  is  best  accom- 
plished hy  diuretics  and,  when  the}'  are  not  siitflcient, 
the  coincident  use  of  cathartics.-  Cathartics  and  the 
preparations  of  jaborandi  must  be  emplo3'ed  with  cau- 
tion when  a  patient  is  debilitated  or  has  heart-weakness. 


CHAPTER   II. 

Trachitis  and  Bronchitis. 

The  words  trachitis  and  bronchitis  are  applied  to 
acute  and  chronic  catarrhal  inflammations  of  the  trachea 
and  the  bronchial  tubes.  Besides  the  simple  form  there 
are  specific  forms  of  bronchitis,  such  as  tubercular. 
They  are  best  considered  separateh'.  Usually,  both  the 
trachea  and  the  bronchi  are  simultaneously  affected,  but 
in  differing  degrees  of  severity.  The  inflammation  may 
centre  in  the  trach-ea  and  scarcely  involve  the  bronchi ; 
the  disease  will  then  be  recognized  as  trachitis  On  the 
other  hand,  if  it  centres  in  the  larger  bronchi,  it  is  de- 
scribed as  simple  bronchitis,  and,  if  in  the  smallest, 
as  capillar}^  bronchitis. 

Anatomy  of  Acute  Simple  Bi-onchitis. — When  the 
bronchial  tubes  are  acutely  inflamed,  tlie  first  change 
that  occurs  is  congestion  of  the  submucosa,  which  is 
almost  immediately  followed  b}'  swelling,  in  part  due  to 
the  congestion  and  in  part  to  a  serous  exudate  which 
fills  the  tissue.  Simultaneously^,  the  basement  mem- 
brane thickens  and  the  epithelial  cells  resting  upon  it 
are  loosened  from  one  another.  If  the  irritation  which 
excites  the  inflammation  is  severe,  the  submucosa  fills 
with  wandering  round-cells  of  leucoc3'tal  origin.  These 
cells,  at  first,  are  most  numerous  about  the  vessels,  but 
soon  fill  the  tissue  diffusel}^  and  in  some  cases  pene- 
trate and  fill  the  muscular  coat,  and  even  the  peribron- 
chial connective  tissue.  They  also  mingle  with  the 
epithelial  cells  ui)on  the  surface  of  the  bronchial  tubes. 
Before  this  has  occurred,  however,  the  ciliated  epithelial 
cells  are  cast  oflf.  The  denuded  surface  is  composed 
(22) 


Trachitis  and  Bronchitis.  23 

of  embiyonic  epithelial  cells,  which,  so  long  as  the 
cause  of  inflammation  exists  and  the  process  is  active, 
are  unable  to  reform  ciliated  columnar  epithelium.  So 
soon  as  active  tissue  destruction  ceases,  the  epithelial 
surface  is  rapidly  restored  to  a  normal  condition.  The 
exudates,  serous  and  cellular,  are  removed  through  the 
l3-mphatic  channels,  and  perfect  restoration  is  accom- 
plished. While  denudation  of  the  epithelium  is  the  rule 
in  acute  bronchitis,  true  ulceration  is  rare.  The  cells 
of  the  mucous  glands  are  usuall}^  swollen,  and  the 
calibre  of  their  ducts  is  diminished  in  part  by  this  swell- 
ing and  in  part  b}'  compression  by  the  swollen  sur- 
rounding tissues.  The  occurrence  and  the  degree  of  all 
tiiese  changes  var}-  with  the  severity  and  duration  of  the 
inflammation.  Many  of  them  are  wanting  in  the  mildest 
cases. 

The  inflamed  tissue  is  redder  than  natural,  although 
the  congestion  is  generall}'  not  evident  to  the  naked  eye 
when  post-mortem  examinations  are  made,  and,  if  pres- 
ent, usually  is  seen  in  patches,  and  not  uniformly  dis- 
tributed. The  mucous  surface  of  the  trachea  or  the 
large  bronchi,  when  inflamed,  appears  swollen  and  soft 
and  has  a  dull  gloss.  In  the  opening  stage  of  conges- 
tion it  is  unusually  dry  ;  later,  it  is  covered  with  a  larger 
amount  of  serum  and  mucus  than  is  natural.  At  first 
the  exudate  is  viscid  and  tenacious;  soon,  however,  it 
becomes  more  dilute  from  the  admixture  of  serum  which 
partl}^  forms  it.  It  loses  its  early  vitreous  appearance, 
and  is  made  whitish  b}'  degenerated  and  cast  off  cells. 
If  the  inflammator}'  process  is  severe  or  at  all  prolonged, 
the  exudate  becomes  j^ellowish  from  the  addition  to  it 
of  round-cells  of  leucocytal  origin,  that  resemble  in  all 
respects  pus  cells.  The  exterior  of  lungs  in  which  the 
bronchi  have  been  inflamed  presents  no  abnormal  ap- 


24  Diseases  of  the  Bronchi. 

peariiiices.  When  a  section  of  them  is  made  there  flows 
from  the  cut  surface,  and  chiefly  from  the  ends  of  the 
divided  bronchi,  a  frothy  mucus.  Muco-purulent 
matter,  also,  can  usually  be  expressed  from  the  latter. 
In  simple  acute  bronchitis  these  changes  are  found  to 
be  symmetrical!}'  distributed  in  both  lungs. 

Physiological  Distui^hance. — The  swelling  of  the 
mucous  membrane  of  the  trachea  or  the  larger  bronchi 
is  not  sufficient  to  cause  noticeable  obstruction  to  res- 
piration. The  unusually  dry  condition  of  the  mucous 
membrane  in  the  earliest  stage  of  inflammation  prevents 
the  straining  of  the  air,  which  is  normallj'  accomplished 
by  the  adherence  of  foreign  particles  to  the  mucus 
which  covers  its  surface,  and  their  removal  b}'  the  cilia 
of  the  columnar  epithelium.  After  desquamation  has 
occurred,  even  though  the  surface  is  abundanth^  covered 
with  mucus,  dusts  are  imperfectl}'  removed  and  maj', 
therefore,  prove  the  source  of  additional  irritation. 

Ayiatomical  and  Physiological  Changes  of  Capillary 
Bronchitis. — In  acute  inflammation  of  the  capillar}^ 
bronchi  the  same  anatomical  changes  are  observable ; 
but  the  difference  in  their  normal  structure  leads  to 
greater  physiological  perversions  than  are  present 
when  only  the  larger  tubes  are  involved.  The  calibre 
of  the  smaller  bronchi  is  proportionately  very  much 
less  than  of  the  larger,  because  of  the  deep  infolding 
of  the  mucous  membrane.  For  the  same  cause  a  trans- 
verse section  of  a  bronchiole  is  stellate.  Owing  to 
these  peculiarities  the  same  degree  of  swelling  which 
in  the  larger  ])ronchi  will  cause  no  respiratory  obstruc- 
tion will  greatly  interfere  with  it  in  the  smaller  ones  ;  and 
a  moderate  amount  of  mucus,  cast-off  epithelium,  and 
detritus  from  cellular  degeneration  will  produce  complete 
obstruction.     Dyspnoea,  more  or  less  intense,  is,  there- 


Trachitis  and  Bronchitis^.  25 

fore,  a  characteristic  of  capillary  bronchitis.  There  is 
a  decided  tendeiic}',  also,  and  especially  in  very  severe 
and  in  chronic  cases,  for  the  inflammation  to  extend 
through  tlie  bronchiole  to  the  surrounding  lung-tissue, 
and  to  produce  peribronchitis  or  catarrhal  pneumonia. 

Complete  obstruction  of  the  bronchioles  leads  to  a 
circumscribed  collapse  of  the  alveoli  communicating 
with  them.  (See  page  67.)  It  is  rare  that  such  patches 
of  collapsed  lung  are  large,  or  even  very  numerous. 
Partial  obstruction  leads  to  the  production  of  emph}'- 
sema.  It  is  difficult  for  air  to  pass  through  the  inflamed 
bronchioles,  both  in  expiration  and  insj)! ration  ;  but  as 
the  former  is  almost  wholly  a  passive  act,  being  pro- 
duced by  the  elasticit}^  of  the  lung  and  by  the  weight 
of  the  thoracic  and  abdominal  walls,  it  is  not  a  very 
forcible  one ;  but  the  latter  is  an  active  one  produced 
by  muscles  of  considerable  power,  and,  accordingly,  is 
much  the  more  forcible.  Therefore,  air  will  enter  the 
lungs  through  partly  obstructed  bronchioles,  but  will 
be  very  imperfectly  emptied  through  them.  Thus, 
slowly  an  increment  is  constantly  added  to  the  alveolar 
contents,  and  dilatation  ensues.     (See  page  61.) 

Emphysema  is  exceedingly  common  as  a  complica- 
tion of  bronchiolitis  ;  indeed,  it  is  to  some  extent  a 
constant  accompaniment  of  it.  It  may  involve  the  lung 
quite  diff"usely.  The  production  of  emphysema  in  bron- 
chiolitis is  aided  by  the  increased  air-pressure  which  is 
produced  in  the  tubes  by  severe"  coughing. 

A  frequent,  severe,  and  dreaded  complication  is 
catarrhal  pneumonia.  (See  page  82.)  This  is  devel- 
oped in  part  b}'  an  extension  of  inflammation  from  the 
bronchioles  to  the  alveoli  communicating  with  them, 
and  in  part  by  an  extension  through  their  walls  to  the 
contiguous  alveoli.     Minute  and  infrequent  patches  of 

2    B 


26  Diseases  of  the  Bronchi. 

consolidation  tlius  produced  are  often  encountered  in 
cases  of  capillary  bronchitis.  Occasionally  the}'  are 
very  numerous,  and  form  a  severe  complication.  They 
rarely  coalesce  in  sufficient  numbers  to  produce  extensive 
areas  of  consolidation. 

Anatomy  of  Chronic  Bronchitis. — The  anatomical 
changes  wrought  hy  chronic  bronchitis  are  various,  and 
occur,  in  the  same  case,  in  var3'ing  combinations  and  in 
different  parts  of  the  bronchial  system.  The  mucous 
membrane  is  usuall}^  grayish  or  brownish  red.  It  may 
be  thickened.  Papilliform  outgrowths  and  excrescences 
are  not  uncommon.  Unusual  tiiinness  of  the  mucous 
membrane  is  quite  as  characteristic  as  increased  thick- 
ness. Especially  in  sacculated  dilatations  the  epithelium 
is  apt  to  be  pavement-like  and  the  surface  to  resemble 
more  a  serous  than  a  mucous  membrane.  The  connective 
tissue  is  uniformly  hypertrophied  to  a  greater  or  less  ex- 
tent. When  acute  exacerbations  of  the  chronic  trouble 
occur,  the  submucosa  is  filled  with  round-cells,  and  all 
the  usual  changes  incident  to  acute  inflammation  are 
observable  in  the  other  bronchial  tissues.  Peribronchial 
inflammation  is  usually  present  in  severe  cases,  especially 
if  the  smaller  bronchi  are  involved.  As  a  result  of  it 
the  bronchial  wall  seems  greatly  thickened  and  supported 
at  points  by  considerable  masses  of  firm  connective 
tissue  that  extend  out  into  the  neighboring  lung-struc- 
ture. This  connective  tissue  develops  from  a  thick- 
ening of  the  alveolar  walls  b}'  inflammatory  exudates. 
In  its  formation  many  alveoli  are  obliterated;  others 
are  narrowed  and  distorted.  The  muscular  layers  of 
the  bronchi  are  often  atrophied  and  the  individual  fibres 
separated  by  new  connective  tissue.  In  the  larger  tubes 
the  cartilages  are  also  at  times  atrophied.  The  bundles 
of  elastic  fibres,  which  are  more  or  less  numerous  in  the 


Trachitis  and  Bronchitis,  27 

bronchi,  remain  unchanged  or  are  hypertrophied.  Occa- 
sionally the  interior  of  a  bronchus  will  present  a  fenes- 
trated appearance,  the  mucous  surface  being  ridged  both 
longitudinally  and  transversely.  This  appearance  is  due 
to  the  atropli}^  of  the  bronchial  wall  and  especially  of  the 
muscular  fibres,  and  to  the  unchanged  condition  or  hyper- 
troph}^  of  the  elastic  fibres  which  produce  the  ridges. 

The  mucous  glands  may  be  quite  normal  in  appear- 
ance. Often,  however,  they  are  changed.  Man^^  atroph}^ 
They  may  even  disap[)ear  entirely.  Sometimes  the  duct 
becomes  funnel-shaped  and  opens  with  a  wide  mouth 
upon  the  surface  of  the  bronchial  tube.  In  otiier  cases 
it  is  obstructed  or  compressed  by  the  swollen  surround- 
ing tissue,  and  consequently  the  deeper  portion  of  the 
gland  is  converted  into  a  small  retention-cyst. 

Abrasions  of  the  mucous  surface  in  chronic  bron- 
chitis are  numerous  and  often  extensive.  Ulceration  is 
not  rare,  but  usuall^^  is  limited  to  dilated  portions  of 
the  bronchi. 

Moderate  chronic  emphysema  is  the  rule.  When 
the  larger  bronchi  alone  are  involved  this  lesion  is 
chiefly  confined  to  the  anterior  and  lower  border  of 
the  lungs.  It  is  then  due  to  severe,  frequent,  and  pro- 
longed coughing.  When  the  smaller  bronchi  are  in- 
volved the  emphysema  is  more  extensive  and  more  gen- 
eralized, and  is  due  to  the  same  causes  that  produce  it 
in  acute  bronchiolitis. 

A  frequent  complication  is  bronchiectasis.  (See 
page  57.)  The  dilated  bronchus  is  usuallj'  cylindrical 
in  shape,  but  may  be  sacculated  and  ver^^  large.  Ulcera- 
tion upon  the  surface  of  the  dilatation  is  of  frequent 
occurrence.  It  may  lead  to  an  enlargement  of  the  cavity, 
and  rarely  permits  its  contents  to  escape  into  the  lung- 
tissue  by  penetrating  the  bronchial  wall.     This  accident 


28  Diseases  of  the  Bronchi. 

almost  invariably  provokes  gangrene  of  the  lung.    (See 
page  112.) 

The  contents  of  clironically  inflamed  bronchi  vary 
greatl}'.  The}'  may  contain  tenacious,  adhesive,  vitreous 
mucus  in  slightly  larger  quantities  tlian  is  normal.  More 
frequently  tliey  contain  a  larger  amount  of  frothy  mucus, 
which  is  not  verj'  adhesive,  and  in  places  some  muco- 
purulent matter.  Rarely,  a  bronchial  dilatation  will 
contain  enormous  quantities  of  serous  fluid  or  pus. 
Either  of  these  exudates  may  become  fetid  from  the 
occurrence  of  putrefaction  within  the  bronchi. 

Symptoms  of  Acute  Trachiiis  and  Bronchitis. — All 
grades  of  severity  of  inflammation  of  the  trachea  and 
the  larger  bronchi  are  observed,  from  a  cold  so  mild  as 
to  be  almost  unnoticed  to  one  tiiat  causes  fever  and 
general  disturbances  that  necessitate  confinement  to  the 
liouse  and  often  to  t4ie  bed.  In  tlie  severer  cases,  both 
of  trachitis  and  bronchitis,  the  sufferer  observes  the  same 
subjective  S3'mptoms.  The}'  are  distinguishable  onl}' 
by  physical  signs. 

In  moderatel}^  severe  cases  of  these  affections  their 
onset  is  usuall}^  marked  b}'  a  sensation  of  chilliness,  or 
sensitiveness  to  draughts  or  changes  of  temperature,  and 
more  rarely  b\'  an  actual  rigor.  The  transitor}^  but  con- 
stantl}' -recurring  chillv  sensations  are  felt  for  several 
hours.  During  this  time  the  patient  often  sneezes  and 
begins  to  feel  a  mental  and  physical  heaviness  or  lan- 
guor. Actual  headache  of  a  dull  character  is  frequenth' 
felt.  Cough  is  an  early  symptom,  nnd  at  first  it  is  not 
severe,  but  rapidly  increases  in  severity.  Witii  it,  and 
even  with  deej)  breathing,  a  feeling  of  rawness  and  sore- 
ness is  felt  beneath  the  sternum,  which  is  due  to  the 
tracheal  inflammation.  The  nose  and  throat  may  or 
may  not  be  simultaneously  inflamed. 


Trachitis  and  Bronchitis.  29 

As  the  chilly  sensations  disappeur  fever  develops, 
and  the  skin  becomes  diy  and  hot.  The  temperature 
is  rarely  high  except  in  children.  Coincidently  and 
dependent  upon  the  increase  of  temperature,  the  pulse 
becomes  quick  and  respiration  slightly  hurried.  A  gen- 
eral muscular  aching  over  the  body  is  felt.  On  the 
second  day  the  soreness  beneath  the  sternum  is  more 
constant.  The  cough  is  more  severe  and  frequent. 
Often  it  is  sufficient  to  cause  muscular  soreness  about 
the  waist,  in  the  epigastrium  and  loins.  As  ^^et  the 
cough  is  unaccompanied  b}^  expectoration.  On  the 
third  day,  or  often  a  little  earlier,  a  scant,  vitreous, 
slightly  frothy  sputa  is  expelled  b}^  coughing.  It 
rapidly  becomes  more  abundant  and  more  easily  raised. 
Usually,  it  is  more  frothy  and  in  part  muco-purulent. 
The  fever  now  disappears.  The  tracheal  soreness  is 
much  lessened  or  gone;  and  as  the  cough,  though  still 
frequent,  is  less  severe,  the  abdominal  muscular  sore- 
ness disappears.  Recovery  is  usually  completed  \ty  the 
seventh  or  tenth  day. 

So  long  as  the  fever  lasts,  appetite  is  wanting  or 
capricious.  The  bowels  are  usually  inactive.  The 
urine  is  somewhat  diminished  in  quantity  and  dark 
in  color. 

A  physical  examination  demonstrates  tlie  involve- 
ment of  the  bronchi  ;  but  in  sim[)le  trachitis  no  ab- 
normal physical  signs  are  discoverable  in  the  thorax. 
If  the  chest  is  examined  in  the  latter  cases  the  only 
abnormalit}'  observable  may  be  a  quickening  of  the 
respirator}^  movements  when  the  i)ntieut  is  feverish. 
When  there  is  bronchitis,  vocal  fremitus  is  usuall}' 
normal.  Rarely,  a  bronchial  fremitus  can  be  felt.  Reso- 
nance is  natural.  Auscultntion  reveals  in  the  earl}' 
stage  dry  rales,  which  are  coarse  when  the  large  tubes 


30  Diseases  of  the  Bronchi. 

only  are  inflamed,  and  fine  when  the  smaller  ones  are. 
Later,  when  the  exndate  within  them  becomes  thinner, 
moist  rales,  coarse  or  fine,  according  to  their  location, 
are  audible.  The  moist  rales  are  not  heard  continuonsl}^ 
in  one  place,  but  ma}^  disappear  after  coughing,  to  be 
discovered  elsewhere  ;  or,  they  may  be  heard  for  a  few 
moments,  disappear,  and  not  re-appear  for  man}^  min- 
utes. If  the  exudate  is  very  abundant  and  the  inflam- 
mation quite  diffuse,  the  rales  may  be  continuous. 

Symptoms  of  Acute  Capillary  Bronchitis. — Acute 
capillar}'  bronchitis  oftener  begins  with  a  rigor  of  some 
duration,  which  is  followed  at  once  by  fever.  Frequent, 
dry,  and  hard  coughing  is  at  once  noticeable.  The 
breathing  gradually  becomes  quicker,  more  labored,  and 
productive  of  the  subjective  sensations  of  d3'spnoea.  In 
thirt3'-six  hours,  and  often  much  earlier,  the  disease  has 
become  severe,  and  endangers  life.  The  patient's  coun- 
tenance is  anxious  and  disturbed.  The  face  is  somewhat 
congested  ;  the  lips  full,  and,  as  the  d^^spnoea  deepens, 
livid;  the  nares  open  wideh'  with  each  inspiration.  The 
rapidity  and  labor  of  breathing  increases.  It  is  often 
noisy,  expiration  producing  a  prolonged  wheeze  or 
whistle.  So  diflScult  is  breathing  that  a  sitting  posture 
is  constantly  ke})t  rather  than  a  reclining  one.  Young 
children  are  most  comfortable  when  held  or  carried. 
The  cough  continues  frequent,  harsh,  and  wearying.  It 
is  accompanied  b}'  little  expectorate,  and  in  young  chil- 
dren usually  b}'  none.  The  skin  is  hot  and  dry;  the 
temperature  ranges  from  101°  F.  to  103°  F.,  the  higher 
temperature  being  most  frequently  observed  in  children. 
The  temperature  is  highest  at  night,  but  is  usually  nearly 
or  quite  normal  in  the  morning.  The  pulse  is  quick  ;  at 
first  full  and  firm. 

If  the  disease  tend  to  a  fatal  termination  the  dysp- 


Trachitis  and  Bronchitis.  31 

noea  is  greater  and  cj-anosis  is  marked.  The  face  is 
aslien  ;  the  lipsand  finger-nails  are  purplish ;  the  skin  is 
cold  and  clanim}'.  The  pulse  grows  small,  soft,  and 
quicker.  The  patient  is  somnolent  or  nearl}^  uncon- 
scious ;  is  now  too  feeble  to  sit,  and  lies  upon  his  back, 
with  his  head  buried  deeply  in  the  pillow,  and  mouth 
open.  Respiration  grows  shallow ;  less  wheezing  is 
heard,  but  a  constant  rattle  in  the  throat  replaces  it. 
Respiration  becomes  irregular  for  a  few  minutes,  a  few 
convulsive  movements  pass  over  the  body,  and  breathing 
ceases.  In  these,  the  commoner  cases,  death  is  caused 
by  suffocation.  Less  frequently,  heart-failure  is  its 
immediate  cause. 

Although  capillary  bronchitis  must  be  regarded  as 
one  of  the  severe  acute  diseases,  fortunately  a  large 
proportion  of  those  who  suffer  from  it  recover.  Im- 
provement nsuall}^  begins  by  the  third  or  the  fifth 
day,  although  at  times  it  begins  several  da3'S  later. 
The  cough  is  easier  and  more  satisfactory,  as  with  it 
an  expectorate  is  raised.  This  at  first  consists  of  small 
lumps  of  vitreous  mucus,  but  soon  consists  of  large  quan- 
tities of  frothy  mucus,  in  which  are  imbedded  small  muco- 
purulent chunks.  If  this  latter  expectorate  is  thrown 
on  water  the  frothy  mucus  floats,  and  from  it  dangle 
minute  muco-purulent  strings,  which  have  been  formed 
in  the  small  bronchi.  The  fever  gradually  lessens. 
Respiration  is  less  hurried  and  difficult.  The  skin  is  no 
longer  hot  and  dry,  but  natural.  The  appetite  improves. 
Strength  is  gradually  regained.  Somewhat  slowly  health 
is  restored. 

In  severe  acute  attacks  the  suflTerer  is  much  weak- 
ened and  often  considerably  emaciated.  In  less  severe 
cases  and  in  those  that  are  subacute  or  chronic,  nutri- 
tion is  little  interfered  with.     Relapses  are  especially 


32  Diseat^es  of  the  Bi'onchi, 

frequent  in  capillary  bronchitis,  and  must  be  guarded 
against  with  unusual  care. 

Ph3^sical  examinations  show  a  chest  that  is  enlarged. 
In  severe  cases  the  chest  is  constantly  in  the  inspira- 
tory position.  During  respiration  the  ribs  move  little  ; 
the  intercostal  spaces  are  persistent!}'  stretched,  and 
inspiration  is  produced  b}-  a  lifting  of  the  entire  chest 
by  the  unusual  muscles  of  respiration.  The  degree  to 
which  these  changes  develop  depends  upon  the  severity 
of  the  attack  and  upon- the  amount  of  coincident  emph}'- 
sema.  The  frequency  of  respiration  is  increased  in  pro- 
portion to  the  intensity  of  the  dyspnoea.  In  young 
children  the  lower  ribs  and  the  abdomen  are  deeply 
pressed  inward  during  inspiration,  the  intra-thoracic 
pressure  being  low,  because  of  the  bronchial  obstruc- 
tion. In  adults,  in  whom  the  ribs  are  firm  and  little 
pliable,  the  intercostal  spaces  onl}-  are  pressed  in,  and 
the  abdominal  wall  is  crowded  back  toward  the  spine. 
Tenderness  over  the  chest  is  often  noticeable,  and 
especially  in  children.  No  abnormal  fremitus  is  ob- 
servable unless  a  complication  has  caused  somewhat 
extensive  consolidation  of  lung-tissue.  On  percussion, 
resonance  is  found  to  be  normal  or,  from  the  emphy- 
sema, somewhat  increased,  and  especiall}-  increased  in 
area  as  the  dilated  lungs  crowd  the  liver  and  heart 
downward  and  overlap  the  latter.  Auscultation  reveals 
fine  rales,  either  moist  or  dry.  The  vesicular  sounds 
are  obscured  by  them  or  are  lacking.  The  inspiratory 
sound  is  short  and  the  expiratory  feeble  and  prolonged. 
These  modifications  of  the  respiratory  sounds  are  best 
heard  over  tlie  lower  and  posterior  ])arts  of  the  chest. 
The  characteristic  fine  rales  are  often  noticed,  or  are 
mixed  with  coarse  ones,  when  the  large  bronchi  are 
simultaneously  aff'ected. 


Trackitis  and  Bronchitis.  33 

When  the  common  complication  of  catarrhal  pneu- 
monia (see  page  82.)  exists  the  physical  signs  are  rarely 
modified  ;  for  tlie  consolidation  of  lung-tissue  does  not 
involve  areas  of  sufficient  size  to  produce  increased 
vocal  fremitus,  duUuess,  or  bronchial  respiration. 
Sometimes,  however,  the  affected  lobules  are  so  close  to- 
gether tliat  physical  sigus  of  consolidation  can  be  dis- 
covered. Catarrhal  pneumonia  causes  an  increase  in 
temperature  if  it  is  at  all  extensive,  the  evening  tem- 
perature ranging  then  above  103.5*^  F. ;  and  all  the 
symptoms  are  intensified,  though  not  changed  in  char- 
acter. Many  mild  cases  of  capillary  bronchitis  are 
seen  in  which  the  symptoms  that  have  been  described 
are  observable,  but  in  less  severe  or  in  a  modified  form. 

Symptoms  of  Chronic  Bronchitis. — Inflammation  of 
the  bronchial  tubes  may  be  chronic  in  character  from 
the  first,  or  acute  bronchitis  may  become  chronic. 
There  are  also  numerous  subacute  cases  which  present 
a  mixture  of  the  symptoms  of  those  that  are  acute  and 
chronic.  The}^  last  several  weeks.  Chronic  bronchitis 
is  of  very  frequent  occurrence.  Many  S3anptoms  are 
common  to  all  cases  and  man\'  more  are  variable.  It  is 
therefore  a  disease  whose  ph^'siognom}'  is  multiform. 
Its  duration  is  indefinite.  Often  it  will  last  for  ten, 
twent}^,  and  even  more  years.  It  does  not  lead  to  fatal 
results  except  when  complicated  by  other  ailments.  Its 
course  is  not  one  of  uniform  severit^^,  but  frequent  ex- 
acerbations and  remissions  are  the  rule.  Different  varie- 
ties of  the  disease  also  var^^  in  severit}'.  In  general, 
we  ma}^  say  that,  the  longer  it  lasts,  the  severer  grow 
the  symptoms  which  are  constantly  present.  Often  the 
exacerbations  resemble  in  all  respects  acute  bronchitis. 

The  state  of  general  nutrition  of  those  who  suffer 
from    chronic    bronchitis    varies    greatl}^,   and    is    not 

2* 


34  Diseases  of  the  Bronchi. 

dependent  upon  the  disease.  We  often  find  chronic 
inflammation  of  both  the  large  and  small  bronchi  in 
those  "who  maintain,  nevertheless,  an  unusual  proportion 
of  flesh  and  are  in  all  ways  robust.  When,  however,  it 
occurs  in  aged  people,  it  usually  prevents  the  accumu- 
lation of  fat,  and  exacerbations  cause  loss  of  both 
weight  and  strength,  which  is  with  difficult}',  if  at  all, 
recovered  from.  Vomiting,  which  often  occurs  imme- 
diately after  eating,  be.cause  of  hard  coughing,  is  seldom 
sufficiently  severe  to  interfere  materiall}'-  with  the  main- 
tenance of  strength.  The  putrid  and  purulent  varieties 
of  bronchitis  are  wasting  diseases,  and  in  this  respect 
resemble  phthisis. 

Uncomplicated  chronic  bronchitis  is  an  afebrile  dis- 
ease. Purulent  and  fetid  bronchitis  are  usuall}'  accom- 
panied b}'^  fever  of  a  hectic  type.  The  pulse  is  normal 
in  rapidity  and  character  unless  sudden  or  violent 
exertion  or  fever  has  quickened  it.  Changes  in  the 
heart  are  not  ver^'  common  ;  rarel}'  its  right  ventricu- 
lar wall  hypertrophies  because  extensive  peribronchitis 
interferes  with  the  pulmonarj'  circulation.  Pain  about 
the  chest  is  not  usual.  In  the  milder  cases,  when  acute 
exacerbations  occur,  tracheal  and,  therefore,  substernal 
soreness  is  felt  during  breathing  and  coughing.  Al- 
though in  chronic  bronchitis  the  cough  is  more  apt  to 
be  very  severe  and  prolonged  than  in  acute,  muscular 
soreness  is  seldom  complained  of  about  the  waist  or  line 
of  attachment  of  the  diaphragm.  This  is  because  the 
muscles  have  become  accustomed  to  the  strain,  and  have 
hypertrophied  in  consequence  of  it.  The  muscles  which 
most  frequently  113'pertrophy  in  chronic  bronchitis  are 
the  recti  abdominalis  and  the  sterno-cleido-mastoids, — 
the  first  because  of  the  persistence  and  severity  of  the 
cough,  and  the  second  because  of  d3-spnGea,  which,  in 


Trachitis  and  Bronchitis.  35 

some  cases,  is  great.  All  who  suffer  from  chronic  bron- 
chitis notice  an  unnatural  shortness  of  breath  on  ex- 
ertion. If  the  bronchioles  are  involved  or  if  there  is 
extensive  peribronchitis,  d3^spnoea,  usually  slight,  though 
varying  much  in  severity,  is  felt  constantly.  Ordinarily 
the  respiratory  movements  are  not  unnaturally  quick, 
but  are  hurried  if  sudden  and  rapid  movements  are 
made  and  also  if  dyspnoea  is  considerable. 

Coughing  occurs  more  or  less  frequentl}^  each  day. 
In  the  mild  cases  it  is  so  infrequent  and  slight  as  to 
escape  the  sufferer's  notice.  When  severe  it  is  apt  to 
be  harsher,  more  prolonged,  and  more  distressing  than 
in  acute  bronchitis;  but  its  character  is  very  variable. 

The  character  of  the  expectorate  of  those  suffering 
from  chronic  bronchitis  is  perhaps  the  best  index  of  the 
nature  of  the  changes  that  are  taking  place  within  the 
bronchi.  Therefore,  upon  its  peculiarities  are  based 
the  varieties  which  are  usually  described. 

1.  Simple  chronic  bronchitis^  or,  as  its  milder  form  is 
often  called,  chronic  winter  covgh^  is  most  common. 
When  mild,  there  is  so  little  coughing  or  respiratory  dis- 
turbance during  the  summer  that  the  existence  of  a 
bronchial  affection  is  not  suspected.  But  each  fall  the 
cough  is  aggravated,  and  is  troublesomelj'  persistent 
until  the  following  summer.  Such  winter  exacerbations 
and  summer  remissions  ma}-  occur  for  years.  XJsuall}', 
as  summer  follows  summer,  the  persistence  of  the  cough 
throughout  the  year  is  more  noticeable.  Occasional 
acute  exacerbations  will  occur  in  hot  weather,  and 
greater  shortness  of  breath,  when  hurried  movements 
are  made,  attract  the  sufferer's  attention.  In  the  severer 
cases  coughing  is  frequent  and  hard  at  all  seasons; 
dyspnoaa  is  troublesome ;  sleep  is  usuall}^  disturbed  by 
coughs  ;  prolonged  or  severe  physical  exertion  is  impos- 


36  Diseases  of  the  Br^onchi. 

sible ;  and  occupations  that  necessitate  exposure  dur- 
ino-  inclement  or  clianoreable  weather  or  the  inhalation 
of  irritating  dusts  must  be  abandoned.  The  amount 
of  expectoration  usuall}^  varies  with  the  severity  of 
the  attack.  It  is  muco-purulent  or,  in  mild  cases, 
froth3\  It  is  most  abundant  and  purulent  in  the  morn- 
ing. Usuall}',  if  purulent  in  the  morning,  it  becomes 
froth}'  and  vitreous  during  the  day.  Coughing  is  almost 
invariably  harshest  in  the  morning,  on  first  arising,  and 
at  night,  on  first  retiring.  Frequently  it  is  provoked 
by  going  into  rooms  or  atmospheres  of  diflerent  tem- 
peratures. 

2.  Dry  bronchitis  occurs  less  frequently  than  the 
preceding  variet}^  It  is  characterized  by  the  absence 
of  expectorate  or  b}'  the  occasional  discharge  of  a 
small  clump  of  tough,  vitreous  mucus,  which  is  loosened 
and  dislodged  with  difficulty.  The  cough  is  especially 
inclined  to  be  harsh  and  parox3^smal.  Asthma  and 
chronic  emphysema  are  frequent  complications  of  it. 

3.  Bronchorrhcea  constitutes  a  third  variety.  Bron- 
chiectasis always  co-exists  with  it.  In  the  dilated  tube 
there  rapidly  accumulates  a  large  amount  of  serous 
fluid,  which  is  expelled  periodical!}' by  coughing.  The 
periodicit}'  of  the  cough  is  ver}"  marked  in  most  cases, 
and  occurs  just  so  soon  as  a  certain  quantity  of  fluid 
accumulates.  The  cavit}'  is  often  emptied  more  fre- 
quently and  more  perfectly  if  the  sufferer  lies  upon  the 
side  in  which  there  is  no  cavity.  In  rare  cases  the 
quantit}'  of  expectorate  is  enormous.  It  may  be  several 
pounds  dail}'.  Its  amount,  its  serous  character,  and 
the  periodicit}"  of  its  expulsion  are  its  important  pecu- 
liarities. 

4.  Purulent  bronchitis  also  occurs  when  bronchi- 
ectasis exists  and  when  the  wall  of  the  cavity  is  exten- 


Trachitis  and  Bronchitis.  3T 

sively  ulcerated.  The  sputa  is  moderate  or  large  in 
amount,  and  consists  of  thin  pus.  It  is  not  raised  in 
formed  lumps,  which  float  separately'  in  a  sputa-cup,  but 
as  mouth fuls  of  liquid  pus,  which  at  once  coalesce  in 
the  cup,  and  resemble  pus  from  an  abscess. 

5.  PutrHd  bronchilis  is  characterized  by  putrefaction 
of  the  contents  of  the  bronchi.  This  ma}'  be  a  compli- 
cation of  either  of  the  other  forms,  but  most  frequently 
is  associated  with  bronchorrlioea.  It  is  most  apt  to  de- 
velop when  the  brouclii  are  imperfectly  emptied  and  tlie 
secretions  stagnate  in  them.  It  leads,  in  serious  cases,  to 
sloughing  of  the  bronchial  walls  and  sometimes  to  gan- 
grene of  the  lung.  When  severe  it  is  a  wasting  disease, 
accompanied  by  hectic  fever.  It  may  terminate  in  a  few 
weeks  if  gangrene  of  the  lung  is  produced,  or  it  ma^' 
last  for  many  months.  Mild  cases  sometimes  recover. 
The  contents  of  the  bronchi  are  so  foul  that  the  breath 
becomes  excessively  offensive.  Its  odor  is  often  plainly 
detectable  by  those  standing  several  feet  from  the 
sufferer.  It  usuall}-  causes  lessened  apj^etite  and  some- 
times nausea  and  vomiting.  The  expectorate  is  consid- 
erable or  very  large  in  amount.  If  collected  in  a  sputa- 
cup  it  separates,  on  standing,  into  three  layers.  The 
uppermost  is  frothy;  the  middle  is  a  serous  fluid;  the 
lower  consists  of  opaque,  granular  matter.  At  the 
bottom  roundish,  gra3'ish-yellow  balls  are  also  found, 
varying  in  size  from  a  pin-head  to  a  pea.  These  are 
extremely'  offensive,  especially  if  compressed.  Under 
the  microscope  the^'  are  found  to  consist  of  granular 
matter,  fat-ciystals,  micro-organisms  of  various  kinds, 
and  filamentous  growths.  These  bodies  are  called 
mykotic  plugs,  and  are  supposed  to  be  the  cause  of  the 
putrefaction.  The  spnta  ceases  to  emit  odor  after  it  lias 
stood  for  a  time,  but  does  aaain  if  it  is  asfitated. 


38  Disease fi  of  the  Bronchi. 

The  pli3'sical  signs  necessarily  vaiy  somewhat  with 
the  severity  and  form  of  the  bronchitis.  Increased 
rapidity  of  respiration  is  noticeable  only  after  greater 
or  less  ph3'sical  exertion,  nnless  emphysema  is  consider- 
able. If  the  bronchitis  has  long  been  chronic,  thoracic 
expansion  is  always  imperfect.  The  subjective  symp- 
toms of  dyspnoea  are  not  felt  in  uncomplicated  bron- 
chitis. Xo  abnormal  fremitus  is  felt  by  the  pali)ating 
hand  unless,  from  extensive  peribronchitis,  considerable 
consolidation  of  lung-tissue  has  occurred.  Thoracic 
resonance  is  also  normal  if  complications  are  absent. 
Auscultation  reveals  the  most  positive  physical  signs. 
In  the  milder  cases  the  normal  respirator}-  sounds  are 
exaggerated  and  roughened.  In  these  cases  occasional 
moist  rales  ma}-  or  may  not  be  heard  here  and  there. 
An  expiratory  sound  is  almost  alwa3'S  present,  Its 
length  and  intensity  var}'  much.  In  the  severer  cases 
vesicular  respirator}-  sounds  are  inaudible  because  moist 
or  dr}-  rales  obscure  them.  So  frequentl}'  are  com- 
plications present  that  the  sounds  are  often  further 
modified  by  them.  If  the  bronchioles  are  involved 
and  emph)'sema  is  considerable,  whistling  and  crowing 
sounds  obscure  all  others.  Bronchiectasis  may  pro- 
duce the  physical  signs  of  a  cavit}-.  Peribronchitis 
ma}'  cause  lung  consolidation,  which  can  be  recognized. 
A  peculiarity  of  the  physical  signs  of  uncomplicated 
chronic  bronchitis  is  the  uniformity  of  their  distribu- 
tion over  all  parts  of  the  chest,  or  at  least  their  sym- 
metrical distribution  on  the  two  sides. 

Diagnosis. — It  is  not  difficult  to  recognize  simple 
acute  bronchitis.  It  is  rarely  mistaken  for  any  other 
disease.  At  times  a  pharyngitis,  laryngitis,  or  trachi- 
tis,  which  produces  a  severe  cough  and  some  systemic 
disturbance,    may    be    mistaken    for   acute    bronchitis. 


Trachitis  and  Bronchitis.  39 

The  absence  of  ph3'sical  signs  of  disease  of  the  bronchi 
and  evidence  of  disease  of  the  upper  portions  of  the 
respirator^'  tract  should  rectify  the  diagnosis.  More 
rarely  an  acute  exacerbation  of  a  mild  chronic  bron- 
chitis is  mistaken  for  the  simple  acute  inflammation. 
This  only  occurs  when  the  history  of  the  case  is  imper- 
fectly obtained.  Occasionally  we  must  differentiate 
between  acute  bronchitis  and  phthisis;  more  frequently 
between  chronic  bronchitis  and  phtliisis.  We  can,  how- 
ever, best  discuss  the  distinouishing  characteristics  of 
each  after  describing  phthisis.     (See  page  138.) 

The  characteristic  symptoms  of  capillary  bronchitis 
and  asthma  have  been  described  (see  page  9)  and  emphy- 
sema will  be.     (See  page  61.) 

Causes. — Bronchitis  in  all  its  forms  is  influenced  by 
the  same  causative  factors,  although  in  varying  degrees. 
It  is  both  a  primary  and  a  secondary  disease.  When  a 
secondary  disease  it  sometimes  results  from  mechanical 
interference  with  the  circulation  of  the  blood  through 
the  bronchial  vessels,  and  sometimes  from  poisonous 
and  infectious  matter  that  is  inhaled  and  causes  the 
bronchitis  and  subsequently  a  disturbance  of  the  whole 
system.  Illustrations  of  the  latter  group  of  cases  are 
seen  in  the  bronchitis  of  measles  and  whooping-cough. 
Many  cardiac  lesions  cause  persistent,  passive  engorge- 
ment of  the  lungs  and  bronchi,  and  lead  to  an  inflam- 
mation of  them. 

Cases  of  primary  bronchitis  are  the  result  usually 
of  both  predisposing  and  exciting  causes.  It  occurs 
at  all  ages.  It  is  sometimes  said  to  occur  oftenest  in 
childhood  and  old  age.  My  own  experience  does  not 
confirm  this  statement.  I  believe  it  occurs  with  about 
equal  frequency  at  all  ages.  It  is  a  more  dangerous 
disease  in  infancy  and  old  age  ^han  at  other  times. 


40  Diseases  of  the  Bronchi. 

Debilit}",  which  lessens  the  power  of  man  to  resist 
disease,  is  one  of  the  most  frequent  predisposing  causes. 
We  therefore  find  bronchitis  of  common  occurrence 
during  convalescence  from  other  troubles.  Anaemia, 
rheumatism,  Bright's  diseases,  and  diabetes  seem  espe- 
ciall}'  to  make  those  suffering  from  them  susceptible  to 
bronchitis.  Bronchitis  itself,  more  than  an}'  other  dis- 
ease, makes  one  susceptible  to  repeated  attacks. 

Enervating  habits  are  frequently  the  cause  of  in- 
creased susceptibility  to  the  disease.  Sedentary  habits, 
and  especially  if  they  necessitate  the  constant  breathing 
of  (\\'y,  warm  air,  predispose  to  all  forms  of  simple  in- 
flammation of  the  respiratory  passages  ;  for  the  cliange 
which  those  subjected  to  such  surroundings  must  ex- 
perience on  passing  from  the  dr\^,  warm,  and  often  close 
air  of  the  house  or  office  to  the  moist,  cold  air  outside, 
such  as  exists  in  temperate  climates  during  the  fall, 
winter,  and  spring,  is  greater  than  any  atmospheric 
change  ordinarily  produced  by  nature.  Air  laden 
with  impurities  is  always  irritating  to  the  respirator}^ 
passages;  therefore,  a  life  of  confinement,  in  poorly 
ventilated  rooms,  increases  one's  susceptibilit}^  to 
bronchial  inflammation. 

The  excessive  use  of  alcohol,  and  even  its  steady 
moderate  use,  is  a  prolific  source  of  inflammation  of 
the  respiratory  passages.  Continuous  excess  causes 
enervation  and  decidedly-  lessens  the  power  of  the 
human  organism  to  resist  disease  of  all  kinds.  The 
benumbing  eflTect  of  alcohol  causes  an  insensibility  of 
those  using  it,  to  cold  and  atmosi)heric  changes,  and  to 
other  exciting  causes  of  bronchitis,  so  that  thej' protect 
themselves  imperfectly. 

There  are  occupations  which  predispose  to  bron- 
chitis.    They  are  such  as  necessitate   the  inhalation  of 


Trachitis  and  Bronchitis.  41 

dust  or  certain  gases.  The  coal-miner,  tlie  stone-cutter, 
and  the  grain-shifter  are  each  exposed  to  dusts  that  are 
frequently  exciting  causes  of  the  disease.  Many  per- 
sons who  are  eniplo3'ed  in  foundries,  in  boiler-rooms, 
and  gas-houses  are  subjected  to  great  heat  at  times,  and 
through  carelessness  expose  themselves  to  rnpid  cool- 
ing. Among  such  pei'sons  bronchitis  or  affections 
etiologically  allied  are  of  constant  occurrence. 

The  exciting  causes  of  bronchitis  are  (1)  most  fre- 
quentl}^  atmospheric  changes,  and  (2)  less  often  irritat- 
ing dusts  or  gases.  The  atmospheric  conditions  which 
most  frequently  provoke  it  are  sudden  depressions  of 
temperature  in  a  moist  atmosphere.  Bronchitis  occurs 
relatively  much  oftener  in  a  moist  than  in  a  dry  atmos- 
phere, for  the  withdrawal  of  heat  from- the  bod}'  takes 
place  much  more  rapidly  when  the  air  is  filled  with 
moisture  and  a  sudden  chilling  of  the  surface  ma}'  be 
thus  produced.  In  a  moist  air  a  sudden  fall  of  tempera- 
ture of  onl}'  a  few  degrees  will  be  felt  more  keenly  b}^ 
the  human  S3'Stem  than  a  fall  of  manj'  degrees  in  a  dry 
air. 

These  atmospheric  conditions  occur  oftenest  in  the 
spring  and  fall,  and  therefore  we  find  cases  of  acute 
bronchitis  or  acute  exacerbations  of  chronic  bronchitis 
most  frequent  in  these  seasons.  They  are  least  frequent 
in  the  dr}'  cold  or  hot  portion  of  winter  and  summer. 
They  are  also  less  frequent  in  years  in  which  the  sum- 
mers are  cool  and  .damp,  and  in  which  there  are  not 
great  extremes  of  temperature  or  other  atmospheric 
conditions. 

Bronchitis  is  more  or  less  prevalent  in  all  climates, 
but  least  so  in  tiie  tropics  and  most  so  in  temperate 
regions,  if  we  except  from  the  latter  such  localities  as 
are  characterized  by  great  dryness. 


42  Diseases  of  the  Bronchi. 

Dusts  and  gases,  which  are  exciting  causes  of  bron- 
chitis, vary  in  their  degrees  of  irritating  power  with 
their  character.  For  example,  dusts  of  vegetable  origin 
are  the  most  irritating,  those  of  animal  origin  a  little 
less  irritating,  and  mineral  dusts  least  so.  Very  few 
cases  result  from  the  inhalation  of  gases,  and  the  most 
irritating  gases,  such  as  bromine,  chlorine,  etc.,  are  not 
commonly  met  with. 

Capillar}'  bronchitis  is  produced  b}^  the  causes  alread}' 
enumerated.  Often  it  is  the  result  of  the  extension  of 
inflammation  from  the  large  bronchi  to  the  small  ones. 
The  exanthemata  and  whooping-cough  among  acute  dis- 
eases, and  Bright's  disease  and  weak  heart  among  chronic 
ones,  especially  predispose  to  it. 

Chronic  bronchitis  is  peculiarly  apt  to  occur  in  those 
who  have  rheumatic,  gout}',  and  scrofulous  diatheses  or 
diabetes. 

Treatment. —  The  prophylactic  treatment  which  is 
applicable  to  bronchitis  is  almost  equally  applicable  to 
all  its  forms.  Many  attacks  of  acute  bronchitis  could 
be  prevented  by  correcting  enervating  habits  and  dis- 
eased conditions  which  predispose  to  bronchial  inflam- 
mations. Not  only  can  acute  attacks  be  often  prevented, 
but  the  tendency  for  acute  inflammation  to  become 
chronic  can  in  the  same  way  be  counteracted. 

The  deleterious  effects  of  atmospheric  changes  that 
are  exciting  causes  of  the  disease  can  be  avoided  by 
keeping  the  skin  covered  with  woole^ii  underwear,  which 
maintains  it  at  a  comparativel}'  equable  temperature. 
Dwelling  in  rooms  whose  air  is  artificially  higlil}-  heated 
and  dried  should  be  avoided  at  all  seasons.  The  best 
indoor  winter  temperature  for  those  who  are  vigorous 
is  68°  F.,and  it  should  not  be  permitted  to  exceed  70°  F. 
The  air  of  offices  and  dwellings  should  be  kept  fresh  by 


TracKitis  .and  Bronchitis.  43 

careful  ventilation,  for  stale  air  is  both  enervating 
and  often  directly  irritating  to  the  air-passages  of  man. 
Especially  should  these  directions  be  kept  in  mind  by 
those  who  are  prone  to  bronchitis. 

The  breathing  of  dust-laden  and  irritating  air  must 
be  avoided  by  all  who  are  predisposed  to  the  disease, 
and  especially  by  those  who  suffer  from  chronic  bron- 
chitis. This  often  necessitates  a  change  of  occupation. 
Grain-shifters  and  others  who  must  breathe  irritating 
dusts  can  frequently  avoid  its  effects  b}'  wearing  a 
respirator.  The  simplest  is  a  sponge  fastened  beneath 
the  nostrils  and  over  the  mouth,  through  which  the  in- 
spired air  is  strained. 

Medicinal  treatment  must  be  varied  with  the  form 
of  the  bronchitis  and  with  the  stage  of  the  inflammation. 
To  lessen  the  frequency  and  severity  of  coughing,  to 
modify  the  secretions  and  excretions  formed  upon  and 
within  the  inflamed  tissues,  are  almost  universal  indica- 
tions for  treatment  in  bronchitis.  To  meet  the  first  of 
these,  opium  or  its  anodyne  alkaloids  are  chiefly  relied 
upon.  The  bromides  are  often  used  instead  for  children, 
but  they  are  not  as  efficacious.  Chloral,  administered 
alone  or  coincidently  with  opiates,  is  exceedingly  useful 
when  coughing  occurs  in  paroxysms  of  nervous  origin. 
If,  however,  the  paroxysms  are  caused  b3^  an  accumula- 
tion of  secretions  in  dilated  bronchi,  chloral  proves  no 
more  eflficacious  than  other  anodynes. 

A  large  number  of  remedies  ma}^  be  used  to  modify 
the  secretions  and  excretions.  Ammonium  chloride  and 
carbonate  are  administered,  in  order  to  render  mucous 
secretions  thinner,  less  adhesive,  and  more  easily  dis- 
lodged. The  carbonate  is  preferable  when  the  finest 
bronchi  or  lung-tissue  is  involved,  but  there  is  little 
choice  when  the  larger  bronchi  are  inflamed.     The  nau- 


44  *     Diseases  of  the  Bronchi. 

seating  expectorants,  such  as  tartar  emetic,  preparations 
of  squills,  and  others,  act  partly'  as  do  the  ammonia 
compounds,  but  are  most  useful  in  aiding  the  expulsion 
of  secretions  from  tlie  bronchi.  It  is  seldom  necessary 
to  resort  to  vomiting  to  empty  the  respirator}'  passages 
of  secretions. 

In  chronic  bronchitis  it  is  often  desirable  to  stop 
sui)purative  inflammation.  The  purulent  character  of 
sputa  can  be  promptly  and  to  a  most  marked  extent 
diminished  b}'  the  internal  administration  of  turpentine, 
Venice  turpentine,  creasote,  and  simihar  drugs.  The 
fetid  quality  of  bronchial  secretions  is  best  counter- 
acted and  its  persistence  prevented  by  the  conjoint 
administration  \)y  the  mouth  of  creasote  and  terebin- 
thines  and  by  the  inhalation  of  volatile  antiseptics. 

In  the  chronic  forms  of  bronchial  inflammation  tlie 
prevention  of  the  development  of  ne^v  tissue  and  the 
thickening  of  the  bronchial  walls  b}'  the  round-celled 
exudate  which  occurs  is  a  common  indication  for  treat- 
ment. The  iodides  exert  the  greatest  influence  over 
these  conditions.  Their  steady  emplo3'meut  apparently 
hinders  the  development  of  adult  from  embr3'onic  tis- 
sue. The  iodides  of  sodium,  potassium,  an<l  ammonium 
are  also  mild  expectorants,  acting  as  do  the  chloride 
nud  carbonate  of  ammonium.  Of  the  iodides  the  ammo- 
nium compound  is  the  best  ex[)ectoraut,  but  is  most 
irritating  to  the  stomach.  Therefore,  as  tliey  must  in 
many  cases  of  chronic  bronchitis  be  emplo3'ed  continu- 
ousl}^  for  long  periods,  the  iodide  of  soda  is  usually  to 
be  i)referred. 

Undoubtedly,  many  threatened  attacks  of  bronchitis 
can  be  checked  or  rendered  abortive.  But  this  is  only 
possible  in  the  stage  of  congestion,  before  inflammation 
is  established,  and  providing  the  exciting  cause  is  re- 


Trachitis  and  Bronchitis.  45 

moved.  If,  just  as  the  chill  is  passing  off  and  tracheal 
soreness  and  coughing  begin,  diaphoresis  is  promptly 
produced  and  simultaneously  a  full  dose  of  opiate  is 
administered,  a  cessation  of  the  development  of  the 
disease  can  be  obtained.  Dover's  powder  is  the  opiate 
that  is  best  adapted  to  this  stage,  and  should  be  given 
in  a  single  large  dose.  Diaplioresis  should  be  estab- 
lished at  the  same  time  by  hot  baths  and  drinks.  The 
opiate  undoubted!}^  lessens  the  irritability  of  the  con- 
gested tissue,  and  the  diaphoretics  deplete  the  congested 
vessels  and  prevent  the  formation  of  exudates  and  other 
phenomena  of  inflammation.  Tliis  mode  of  treatment 
is  well  adapted  to  sthenic  cases  onl}-.  If  the  patient 
is  debilitated  from  an}-  cause,  if  his  tissue-changes  are 
taking  place  slowh',  a  different  abortive  treatment 
proves  more  effectual.  This  consists  in  the  adminis- 
tration of  one  or  two  large  doses  of  quinine  and  an 
opiate.  In  these  cases  there  is  a  lack  of  vascular  tone, 
and,  therefore,  depletion  of  the  congested  vessels  does 
not  lead  to  their  contraction  and  restoration.  Quinine, 
however,  and  strj'chnine  also,  seem  to  stimulate  the 
vasomotors,  so  that  the  lost  vascular  tone  is  reg-ained. 
The  opiate  is  still  needed  to  lessen  the  irritabilit}-  of 
the  bronchial  tissues.  A  capsule  of  quinia  sulphate 
and  morphia  sulphate,  in  doses  of  0.3  gramme  and  0.008 
gramme  (5  and  ^  of  a  grain),  respectivel}^,  is  the  most 
convenient  form  of  administration.  Two  of  these 
should  be  given  at  first,  and  one  every  three  or  four 
hours  afterward,  until  four  or  five  doses  have  been 
taken. 

Unfortunately,  abortive  treatment  can  rarely  be 
applied,  as  patients  do  not  often  seek  a  physician  until 
the  inflammation  is  fairly  established  and  until  it  is  too 
late  to  employ  it  successfully. 


46  Diseases  of  the  Bronchi. 

In  the  dry  stage  of  simple  acute  bronchitis  the  indi- 
cations are  (1)  to  lessen  cough  and  soreness,  (2)  to  pro- 
mote the  formation  of  a  thin  expectorate,  and  in  the 
moist  stage  (3)  to  aid  the  elimination  of  secretions. 
As  the  course  of  the  disease  is  usually  short,  a  formula 
is  generally  advised  which  will  meet  all  of  these  indica- 
tions at  once  ;  such  as  the  following  : — 

1.  R  Ammon.  muriat.,      .        .     grms.    10.0    (3iiss). 

Morph.  muriat.,         .         .     grm.       0  2    (gr.  iv). 
Antim.  et  pot.  tart.,  .     grm.       0.15  (gr.  iiss). 

Syr.  glycyrrhiz.,    q.  s.  ad  c.cm.  120.0    (5iv), 

Sig.  :  Give  of  the  mixture  one  teaspoonful  to  adults  every 
three  to  six  hours. 

2.  R  Sod.  bromid.,    . 

Tinct.  sanguinariae,  . 

Tinct.  opii  camph.,   . 

Syr.  scillse  comp., 

Syr.  tolut.,         .      q.  s.  ad     c.cm.  120.0  (^iv). 

This  can  be  given  in  the  same  doses  as  the  last,  but 
more  frequently,  if  needed.  All  expectorant  mixtures 
are  more  or  less  nauseating,  and  diminish  the  appetite 
and  make  digestion  slow.  The  second  formula,  while 
less  efficient  as  a  cough-mixture,  causes  verj'  little  dis- 
turbance of  the  stomach.  I  have  found  frequentl}'  that 
when  the  stomach  is  peculiarl^^  sensitive  the  following 
capsule  proves  efficient : — 

R  Ammonii  chloridi,     .         .     grm.  0.06    (gr.  j). 
Codeise,      ....     grm.  0.012  (gr.  \). 

One  should  be  administered  each  hour.  When  the 
larynx  and  trachea  are  cliiefl}'  involved,  a  compressed 
tablet  of  the  following  ingredients  is  exceedingly 
useful : — 

R  Terpin.  Iiydrat.,         .         .     grm.  0.12    (gr.  ij). 
Extract,  cannabis  Indica?,     grin.  0.003  (gr.  ^). 
■     Codeiae,     .        .        .        .     grm.  0,008  (gr.  |). 


grms. 

20  0  (3v). 

c.cm. 

10.0  (Siiss). 

c.cm. 

45.0  (|iss). 

c.  cm. 

45.0  (5iss). 

Trachitis  and  Bronchitis.  4Y 

They  may  be  given  alone,  one  every  half-hour  or 
hour,  with  less  frequent  doses  of  expectorant  mixtures. 
They   should  be  allowed  to  melt  gradually  in  the  mouth. 

The  fever  of  bronchitis  rarely  requires  especial 
treatment.  In  ad3^namic  cases,  or  when  debility  is  a 
prominent  feature,  moderate  doses  of  quinine  are  useful 
(from  grm.  0.15  to  0.25).  In  sthenic  cases  aconite  may 
be  used,  and  may  contribute  materiall}^  to  lessen  fever 
and  to  produce  a  feeling  of  greater  well-being.  To 
children  who  sometimes  have  high  temperature  and 
consequent  delirium,  a  few  doses  of  antipyrin  can  be 
given  most  advantageously. 

Many  mild  cases  of  acute  bronchitis  require  no 
treatment,  and  numerous  complications  necessitate  a 
modification  of  the  course  just  sketched.  It  is  desira- 
ble that  the  bowels  be  kept  regular.  As  the  opiates 
which  are  usually  required  cause  constipation,  a  laxative 
must  be  administered. 

The  indications  for  treatment  in  acute  capillary 
bronchitis  are  (1)  to  maintain  strength,  both  (a)  gen- 
eral and  (b)  cardiac ;  (2)  to  relieve  dyspnoea  hy  (a) 
loosening  and  (b)  expelling  the  secretions  from  the 
bronchioles. 

The  course  of  simple  acute  bronchitis  is  so  short, 
and  ordinaril3^  the  general  strength  of  a  patient  is  so 
little  affected,  that  special  dietary  directions  are  unnec- 
essary. In  capillary  bronchitis,  however,  very  great 
and  rapid  physical  prostration  is  produced.  Often, 
cardiac  weakness  is  developed,  which  greatly  increases 
the  danger  to  life.  For  these  reasons  the  sufferer's 
strength  must  be  preserved.  A  diminished  appetite, 
and  even  a  disinclination  for  food,  is  the  rule  in  this 
disease.  Therefore,  feeding  should  take  place  with  as 
much  regularity  as  the  administration  of  medicine,  and 


48  Diseases  of  the  Bronchi. 

should  not  be  governed  by  appetite.  The  food  should 
be  concentrated,  and  in  such  a  form  that  it  is  most 
easily  digested.  Milk  and  milk-gruels  are  probably  the 
best  foods.  Occasionally-,  to  var^^  the  diet,  meat-broths 
can  be  advantageously  given,  or  soft  cooked  eggs  or 
raw  eggs  beaten  up  in  the  milk.  The  food  is  best 
administered  in  small  quantities  during  the  severest 
part  of  the  attack,  and  frequently'  repeated,  so  that  the 
stomach,  which  is  doing  its  work  slowl}',  may  not  be 
overloaded.  And  even  when  disinclined  for  food  a 
patient  will  take  two  or  three  teaspoon  fuls  without  dis- 
gust. Especial  attention  must,  in  severe  cases,  be  paid 
to  the  maintenance  of  strength. 

Cardiac  strength  must  be  preserved,  whenever  acute 
failure  is  threatening,  by  the  combined  use  of  diffusible 
stimulants  and  cardiac  tonics.  The  carbonate  of  am- 
monia is  one  of  the  best  diffusible  stimulants.  Its 
effects  are  the  most  promptl}-  obtained  when  it  is  given 
in  solution,  and  they  may  be  somewhat  augmented  by 
dissolving  it  in  camphor-water.  The  doses  should  be 
such  that  the}'  can  be  repeated  as  often  as  every  hour, 
for  the  stimulant  effect  of  the  drugs  is  transitor}^  Ex- 
cellent results  can  be  gotten  from  a  solution  of  camphor 
in  oil  administered  h3'podermaticall3'.  The  effects  of 
alcoholics  under  these  circumstances  can  be  best  con- 
sidered in  connection  with  the  treatment  of  croupous 
pneumonia.  (See  pjv<:e  103.)  If  used,  alcohol  should  be 
given  diluted,  so  that  its  exact  strength  is  known.  Its 
stimulant  effects  on  the  circulation  are  transitory-  and 
are  obtained  only  from  small  doses.  So  soon  as  its 
anesthetic  effects  are  developed,  either  from  the  admin- 
istration of  large  doses  or  small  ones,  frequently  re- 
peated for  some  time,  cardiac  stimulation  is  no  longer 
obtained,  and  the  patient  is  less  likely  to  keep  the  air- 


Trachitis  and  Bronchitis.  49 

passages  clear  hy  coiigliing  and  voluntary  efforts  to 
breathe  deeply ;  congestion  is  prolonged  and  tendencies 
to  congestion  confirmed  because  of  the  lessened  vascu- 
lar tonicity-  which  is  produced.  Furthermore,  alcohol 
in  the  blood  lessens  its  al)ility  to  take  up  oxygen  from 
the  air  inspired.  In  a  word,  it  increases  the  difficulty 
already  existing  of  furnishing  to  tlie  tissues  the  oxygen 
that  they  need.  Digitalis,  or  strophanthus,  which  is 
often  better  in  these  cases,  must  be  used  simultaneously 
with  the  diffusible  stimulants.  As  a  rule,  before  the 
latter  drugs  are  indicated,  when  the  pulse  is  rapid  and 
begins  to  grow  soft  or  small,  digitalis,  or  one  of  its  con- 
geners, should  be  employed  to  stimulate  the  heart's 
contractions  and  prevent  the  development  of  marked 
cardiac  weakness.  Yeratrum  and  aconite  should  never 
be  used  unless  at  the  xery  onset  of  an  attack,  and  then 
the3^  may  act  as  depletors  might, — to  relieve  congestion 
and  prevent  inflammation.  If  used  while  the  heart  is 
laboring  and  growing  weary,  the}'  increase  the  tendency 
to  cardiac  dilatation.  They  are  hardl}'  ever  required  in 
bronchiolitis. 

To  relieve  dyspnoea,  the  air-tubes  must  be  emptied 
of  the  obstructing  secretion  and  the  swelling  of  the  walls 
of  the  finer  ones  lessened.  The  first  of  these  indications 
for  treatment  can  be  met  b}'  rendering  the  secretions 
more  liquid,  and  therefore"  more  easil}^  dislodged.  The 
carbonate  and  muriate  of  ammonia  will  help  to  accomp- 
lish this.  The  inhalation  of  moist  air  is  exceedingly 
beneficial,  as  all  the  moisture  inhaled  at  once  aids  by 
diluting  the  secretions.  Those  suffering  from  severe 
attacks  of  bronchiolitis  should  be  kept  in  rooms  whose 
air  is  at  a  constant  temperature  and  made  moist  by 
evaporating  water.     The  inhalation  of  the  warm  spray 

of   a  steam-atomizer  is   also  useful.      The  patient  can 

3  c 


50  Diseases  of  the  Bronchi. 

render  the  secretions  less  tenacious,  but  also  more 
copious,  b}'  free  libations  of  water  and  fluid  foods. 

Emesis  is  seldom  advantageous.  By  it  the  bronchial 
tubes  are  most  perfectl}^  emptied,  but  the  depression 
which  most  emetics  produce  is  deleterious,  and  often  is 
followed  by  an  irritable  condition  of  tiie  stomach  which 
interferes  with  the  maintenance  of  nutrition.  The  sub- 
sulphate  of  mercury'  causes  prompt  emesis  with  ver}- 
little  depression.-  It  can  be  used. when  there  is  much 
dyspnoea  in  strong  and  vigorous  patients,  but  it  should 
not  be  frequently  repeated.  Oftener  emetics  are  given 
in  small  doses  as  nauseating  expectorants.  Apomorphia 
is  a  favorite  with  man}',  and  is  given  in  doses  of  0.003 
gramme,  or  one-twentieth  of  a  grain,  everj^  two  to  four 
hours.  Similarl}'  tartar  emetic  (dose,  grm.  0.005,  or 
gr.  y^^)  and  syrup  of  squiljs  and  ipecac  (dose,  c.cm.  2  to 
4,  or  5ss  to  j)  can  be  emplo^^ed. 

Forceful  respiration  is  one  of  the  principal  means 
by  which  mucus  is  dislodged  from  the  bronchi.  In 
dyspnoea,  when  voluntary  exertion  flags  and  when  cya- 
nosis develops,  deep  and  forceful  breathing  is  stimulated 
by  sudden  immersion  in  a  bath  or  b}'  a  douche  upon  the 
back  of  the  neck  of  alternating  hot  and  cold  water. 

In  subaeute  and  chronic  cases  much  aid  can  be  ob- 
tained from  inhaling  compressed  and  exhaling  into  rare- 
fied air,  for  then  the  respirator}'  movements  are  aug- 
mented and  surprisingly  large  amounts  of  mucus  emptied 
from  the  bronchi.  Anodynes  and  ansestheties  are  contra- 
indicated  except  in  the  mildest  and  in  chronic  cases.  In 
all  severe  acute  cases  the}'  lessen  cough  and  diminish 
the  force  of  the  respiratory  acts.  This  increases  the 
obstruction  of  the  bronchioles,  and  cyanosis  and  pul- 
monary oedema  are  not  unfrequently  precipitated,  when 
they  should  be  avoided  or  guarded  against. 


Trachitis  and  Bronchitis.  51 

Antipyretics  are  generally  of  no  use.  By  lowering 
the  temperature  they  do  not  remove  the  cause  of  its 
elevation.  They  contribute  little  to  a  feeling  of  well- 
being.  They  lessen  the  power  of  haemoglobin  to  take 
up  oxygen,  and  thus  increase  the  desire  already  felt  for 
it.  Baths  are  useful,  especiallj^  sponge-baths  and  douches, 
because  of  their  stimulating  effects  upon  the  circulation 
and  respiration,  as  well  as  for  their  antipyretic  influence. 
They  are  not,  however,  needed  unless  the  temperature 
is  very  high  or  the  dj-spnoea  ver^^  great.  They  may 
then  be  resorted  to  frequently  with  advantage. 

Some  cases,  mostl}^  of  the  subacute  t3'pe,  are  appa- 
rently- the  result  of  rheumatic  conditions.  The  addition 
of  salicylate  of  soda  and  of  wine  of  colchicum  to  the 
usual  treatment  for  bronchiolitis  often  effects  conva- 
lescence with  wonderful  promptness. 

In  chronic  cases  the  iodide  of  soda,  continuously 
employed,  proves  useful  in  man}-  instances,  but  gener- 
ally does  not  effect  a  complete  cure.  In  the  acute 
cases  nothing  relieves  the  swelling  of  the  mucous  mem- 
brane so  much  as  getting  the  bronchioles  free  from 
obstruction,  so  that  the  varyiug  air-pressure  which  is 
caused  by  respiration  ma^'  promote  a  more  perfect  lym- 
phatic circulation,  and  thereby  absorption  of  inflamma- 
tory exudates. 

The  frequent  complications — emphysema  and  catar- 
rhal pneumonia — will  be  treated  of  separatel}'.  (See 
pages  61  and  82.) 

During  convalescence  the  utmost  care  must  be  taken 
to  avoid  exposure  to  causes  that  might  excite  a  new 
attack.  Atmospheric  changes  must  be  guarded  against 
by  woolen  clothing.  A  ver}^  careful  and  gradual  expo- 
sure to  air  otlier  than  that  of  the  sick-room  must  be 
contrived.     Relapses  can  frequently  be  avoided^  wheij 


52  Diseases  of  the  Broncln. 

recoveiy  is  fairiy  obtained,  b^''  a  change  of  climate  for 
a  winter  from  the  inclement  and  changeable  air  of  north- 
ern temperate  regions  to  localities  warmer  and  more 
equable.  During  convalescence  food  can  be  varied  and 
often  can  soon  be  made  that  of 'health,  as  the  appetite 
returns  and  the  digestive  function  is  restored.  When 
there  is  an  atonic  or  depressed  physical  condition  prior 
to  the  attack  of  bronchitis,  and  occasionall}^  in  other 
cases,  the  appetite  does  not  return  as  the  bronchitis  les- 
sens. Under  these  circumstances,  bitter  tonics,  such  as 
gentian  or  weak  solutions  of  strychnia,  especially  when 
combined  with  active  preparations  of  pepsin  and  with 
h3-drochloric  acid,  are  useful. 

The  general  indications  for  the  treatment  of  chronic 
bronchitis  are  the  same  as  those  for  acute  simple  bron- 
chitis;  but  each  variet}^  affords  additional  important 
indications.  1.  For  example,  it  is  frequenth'  necessar^^ 
to  forcibh'  maintain  permeability  of  the  air-passages, 
in  order  to  overcome  the  dyspnoea  M'hich  develops  from 
the  accumulation  of  secretions  within  the  bronchi  and 
from  the  thickening  of  their  walls.  2.  Less  frequentl}^ 
true  asthma  is  present,  and  must  be  treated.  3.  To 
modify  purulent  and  fetid  secretions  is  another  frequent 
indication  for  treatment. 

What  I  have  termed  chronic  winter  cough,  usually 
the  mildest  and  least  harmful  form  of  chronic  bronchitis, 
must  be  treated  in  the  main  as  is  acute  bronchitis.  This 
form  of  the  disease  can  often,  in  the  first  year  or  two  of 
its  course,  be  cured  by  prophjdactic  measures.  A 
change  of  climate  to  a  warm  and  equable  region  is 
usuall}'-  necessary.  The  general  health  should  be  main- 
tained at  the  highest  degree  of  vigor.  Exposing  occu- 
pations and  unwliolesome  places  of  residence  should  be 
avoided,      Whenever  acute    exacerbations    occur   they 


Trachitis  and  Bronchitis.  53 

should  be  promptly  alhiyed  by  the  usual  medicinal 
treatment  for  acute  broncliitis. 

In  some  of  the  more  chronic  cases,  especially  when 
there  is  moderate  but  persistent  dyspnoea  on  exertion, 
the  iodides  can  be  given  with  advantage.  Their  use 
should  be  continued  for  months  ;  therefore,  the  iodide 
of  soda  is  the  preparation  to  be  preferred.  In  children 
we  obtain  good  results  by  the  persistent  use  of  cod- 
liver-oil.  This  is  true  especialh'  of  those  who  are 
slender  and  not  well  nourished.  In  adults  the  oil  ap- 
pears rareh'  to  accomplish  the  same  results,  because  it 
is  taken  in  comparatively  smaller  quantities,  and  is  more 
apt  to  cause  disgust  or  digestive  disturbances. 

In  dry  broncliitis,  with  its  usual  paroxj^smal  cough, 
much  relief  is  obtained  from  prolonged  or  permanent 
residence  in  a  moist,  warm  climate,  or  In^  the  frequent 
inhalation  of  steam  vapor  or  atomized  vapors.  These 
lessen  the  frequency  and  severity  of  the  cough,  and,  by 
adding  moisture  to  the  mucus  within  the  bronchi, 
render  it  thin  and  more  easily  dislodged.  Chloral  is  an 
efficient  adjuvant  to  opiates  to  modifj^  the  spasmodic 
qualit}'  of  the  cough.  It  may  be  combined  with  ordi- 
nary anodyne  and  expectorant  mixtures,  and  thus  admin- 
istered frequently  in  small  doses  (grm.  0.2  to  0.3);  or,  if 
the  cough  occur  with  much  regularity  it  may  best  be 
administered  in  larger  doses  once  or  twice  daily,  a  little 
before  the  paroxysm  is  expected  to  occur. 

The  persistent  use  of  ammonium  muriate  or  the 
iodide  of  ammonia  or  soda  also  increases  the  liquidity 
and  usually  the  amount  of  secretions.  I  have  often 
thought  the  most  prompt  effects  were  to  be  obtained 
from  small  doses  often  repeated,  as,  for  instance,  from 
12  centigrammes  (2  grains)  of  the  muriate  of  ammonia 
every  hour    or  two.     After   the    secretions    have   thus 


54  Diseases  of  the  Bronchi. 

been  loosened,  the}'  can  iisuall}'  be  maintained  so  by 
using  larger  doses  two  or  three  times  daily.  These 
remedies  interfere  somewhat  witli  digestion  and  with 
the  appetite,  therefore  the}'  cannot  always  be. efficiently 
emplo3'ed  in  clironic  cases.  It  is  often  more  important 
to  maintain  good  nutrition  than  to  ease  a  cough. 

Spasmodic  dyspnoea,  or  true  asthma,  is  to  be  relieved 
by  the  remedies  whose  use  has  been  described  (See 
page  12).  Our  efforts  should  be  especiall}'  directed  to 
tlie  removal  of  the  cause  during  the  intervals  of  normal 
breathing. 

Turpentine  and  similar  drugs  are  especially  adapted 
to  those  cases  in  which  it  is  desirable  to  diminish  the 
secretions  of  the  bronchi  or  to  render  them  less  puru- 
lent. To  this  class  of  remedies  belongs  turpentine-oil, 
terebene,  Venice  turpentine,  copaiba,  eucal^'ptus,  crea- 
sote  (beech-wood),  etc.  It  is  often  surprising  how 
quickl V  a  marlied  diminution  in  the  amount  of  expecto- 
rate can  be  effected  by  these  remedies.  The  secretions 
are  lessened  and  made  more  tenacious.  Therefore,  when 
the  expectorate  is  alread}'  tenacious  and  difficult  to  dis- 
lodge, the  employment  of  these  drugs  makes  expec- 
toration more  difficult  and  coughing  harder  and  more 
prolonged.  Tliey  shoukl  not  be  used  under  such  con- 
ditions. They  are  especiall}^  indicated  when  the  exi)ec- 
torate  is  tliin  and  abundant. 

The  same  drugs  (especially  turpentine  and  creasote) 
will  convert,  often  with  great  rapidity,  a  thin,  purulent 
secretion  into  one  less  abundant  and  muco-purulent. 
They  certainl^^  modify  suppuration  in  the  air-passages. 
Turpentine  is  best  administered  as  an  emulsion.  Venice 
turpentine  can  conveniently  be  given  in  capsules,  in 
doses  of  from  0.05  to  0.20  gramme  (1  to  3  grains). 
Creasote  is  also  convenientlv  administered  in  capsules, 


Trachitis  and  Bronchitis.  65 

in  doses  gradually  increased  from  0.2  to  0.3  gramme 
(3  to  5  minims).  Usually,  these  drugs  must  be  com- 
bined with  anodynes  to  allay  cough. 

The  fermentation  which  characterizes  putrid  bron- 
chitis is  modified  somewhat  by  the  internal  administra- 
tion of  remedies  belonging  to  the  group  that  has  just 
been  described,  mid  most  by  creasote,  eucalyptus,  and 
terebene ;  but  much  more  benefit  is  gotten  from  the 
employment  of  antiseptic  inhalations.  To  cause  anti- 
septics to  penetrate  to  the  deepest  part  of  the  air- 
passages  they  must  be  inhaled  for  hours  at  a  time,  and 
all  the  air  that  is  breathed  impregnated  with  them. 
This  is  best  accomplished  by  using  a  respirator  which 
covers  the  mouth  and  nostrils  and  can  be  worn  for  hours 
consecutively.  The  cotton  or  other  absorbent  which  it 
holds  and  through  which  the  inspired  air  is  drawn  must 
be  saturated  with  carbolic  acid,  eucalyptus-oil,  thymol, 
or  similar  volatile  antiseptic.  Steam  inhalers  and  atom- 
izers are  sometimes  employed,  but  are  of  comparatively 
little  use.  A  Florence  flask  partly  filled  with  hot  water 
to  which  there  has  been  added  a  volatile  antiseptic,  and 
so  arranged  that  air  can  be  drawn  tlirough  the  hot 
medicated  water  for  inhalation,  will  prove  moderately 
efficient ;  but  as  it  cannot  be  used  as  continuously  as  the 
respirator,  it  is  not  to  be  preferred.  By  this  treatment 
putrefactive  changes  can  lie  greatl}'  lessened  and  often 
entirely  prevented.  The  best  results  are,  of  course, 
obtained  in  cases  that  come  early  under  treatment. 

Purulent  and  putrid  bronchitis  is  usually  accom- 
panied by  hectic  fever  and  gradual  but  persistent  loss 
of  flesh  and  strength.  Therefore  we  have,  as  prominent 
indications  for  treatment,  the- maintenance  of  strength. 
This  is  best  accomplished  by  the  systematic  administra- 
tion of  the  most  nutritious  food.     Usually,  the  appetite 


56  Diseases  of  the  Bronchi. 

is  poor  or  capricious;  therefore,  food  must  often  be 
varied.  Exercise  whicli  is  exhausting  must  be  avoided. 
The  fever,  if  it  require  any  treatment,  needs  that  which 
will  be  described  (see  page  159.)  where  tuberculous 
disease  of  the  lunas  is  considered. 


CHAPTER  III. 

Bronchiectasis. 

Anatomy. — Diliitation  occurs  most  frequently  in  the 
medium-sized  bronchi,  rarel}^  in  the  smaller  ones,  and 
still  less  frequently  in  the  large  ones.  It  occurs  with 
equal  frequency  in  both  lungs,  but  oftener  in  the  lower 
and  middle  lobes  than  in  the  upper.  Usually  a  single 
bronchiectatic  cavity  is  formed  on  one  bronchus,  but  a 
number  of  them  may  be.  They  are  then  commonl}'  sep- 
arated from  one  another  by  unusually  narrow  tubes. 
The  cavities  vary  much  in  shape.  They  may  be  fusi- 
form or  sacculated,  round  or  angular.  As  a  rule,  they 
are  not  large ;  but  they  may  occupy  almost  an  entire 
lobe  of  the  lung.  They  differ  from  other  pulmonary 
cavities  in  that  a  single  bronchus  enters  them,  in  that 
their  walls  show  some  of  the  anatomical  elements  of 
bronchial  tubes,  and  in  that  usuall}^  the}^  are  not  angular 
and  are  not  intersected  b}-  bands  of  fibrous  tissue  and 
blood-vessels.  The  walls  of  the  cavity  are  so  modified 
b}^  chronic  inflammation  that  the  anatomical  elements 
characteristic  of  a  bronchial  wall  are  often  obscured  or, 
in  places,  obliterated.  The  mucous  membrane  varies  in 
appearance,  as  it  does  in  chronic  bronchitis,  when  no 
dilatation  exists.  It  may  be  unusuall}^  smooth  and  re- 
semble a  serous  membrane,  the  cylindrical  epithelium 
having  been  shed  and  replaced  b}-  flattened,  pavement- 
like cells.  Or  it  ma}^  be  loose  and  thrown  up  into  folds  ; 
or  from  it  excrescences  may  protrude.  Or  the  surface 
may  be  fenestrated  by  the  atroph}^  of  the  muscular  ele- 
ments  and  persistence   or  h3q)ertroph3^  of  the   elastic 

3*  (57) 


58>  Diseases  of  the  Bronchi. 

fibres.  The  bronchial  tubes  are  often  narrowed  just 
bej'ond  the  cavities  or  obliterated.  The  latter  change 
will  cause  collapse  of  the  lung-tissue  continuous  with 
them. 

Causes. — Bronchiectasis  is  always  a  secondary  lesion. 
It  usually  results  from  chronic  bronchitis,  but  ma}'  result 
from  chronic  inflammation  of  the  lung  or  pleura.  The 
bronchi  are  weakened  by  chronic  inflammation,  especially 
by  ulceration,  and  therefore  become  dilatable.  Increased 
air-pressure,  which  is  caused  b}'  coughing,  helps  to  pro- 
duce their  distension.  Destruction  of  lung-tissue  along- 
side of  a  bronchus  also  weakens  its  wall.  Man}'  saccu- 
lated cavities  are  due  to  ulceration  and  destruction  of  a 
part  of  a  bronchial  wall  and  the  neighboring  lung-tissue. 
The  walls  of  such  cavities  are,  for  the  most  part,  com- 
posed of  granulation  tissue.  Tubercular  ulceration  of 
a  bronchus  is  a  common  cause  of  cavities. 

Interstitial  pneumonia  and  extensive  peribronchitis 
are  lesions  in  the  course  of  whose  development  new 
fibrous  tissue  is  formed  in  extensive  bands.  Contraction 
of  the  newly-produced  tissue  always  occurs  in  these 
bands.  This  will  cause  traction  on  the  bronchus  which 
is  surrounded  by  the  new  growth,  and  will  tend  to  dilate 
it.  Large  cavities  are  not  made  in  this  way  unless,  at  the 
same  time,  adhesions  have  occurred  between  the  costal 
and  visceral  pleura,  which  make  the  thoracic  wall  a 
fixed,  unyielding  point,  from  which  the  contracting 
tissue  can  pull.  Cavities  produced  in  this  way  are 
usuall}'  fusiform,  but  are  sometimes  angular.  Chronic 
pleuris}^,  causing  adhesion  and  the  development  of 
masses  of  connective  tissue  in  the  lung,  beneath  the 
pleura,  sometimes  produces  bronchiectasis  in  a  similar 
way. 

Symptoms. — As  bronchiectasis  is  always  a  secondary 


Bronchiectasis.  59 

lesion,  its  symptoms  must  be  expected  superimposed 
upon  those  of  the  })rimary  one.  .  Often  cavities  of  small 
size  or  deeply  located  cannot  be  discovei-ed  during  life. 
The  characteristic  physical  signs  of  bronchiectasis  are 
those  of  a  pulmonary  cavity.  They  can  be  best  de- 
scribed in  connection  with  tubercular  diseases  of  the 
lungs.  (See  page  133.)  Bronchiectatic  cavities  occur 
both  in  non-tubercular  and  tubercular  troubles.  If  the 
cavity  is  large,  and  especially  if  the  secretions  which  it 
contains  are  thin,  it  is  usually  emptied  periodically  by 
coughing,  and  large  amounts  of  expectorate  are  voided. 
A  cavity  can  frequently  ])e  best  emptied  if  a  patient 
lies  upon  one  side  rather  than  the  other,  or  assumes 
some  position  wliich  enables  the  bronchus  to  drain  it 
with  thoroughness.  To  determine  whether  it  is  tubercu- 
lar or  not,  one  must  ascertain  the  precise  character  of 
the  primar}^  affection. 

Bronchiectatic  cavities,  if  well  drained  b}^  a  bron- 
chus, may  remain  open  and  undergo  little  change  during 
many  years ;  or  they  may  gradually  increase  in  size  and 
destroy  the  lung  extensively.  A  bronchus  may  become 
permanently  obstructed.  The  cavity  is  thus  converted 
into  a  C3^st.  Its  liquid 'contents  may  then  be  absorbed 
and  its  more  solid  contents  transformed  into  cheesy  or, 
finally,  into  calcareous  matter.  A  contraction  and  dimi- 
nution in  the  size  of  a  cavity  frequentlj'  occurs,  espe- 
cially when  it  is  converted  into  a  C3St  by  obliteration  of 
the  bronchus  ;  but  it  ma^'  also  occur  whenever  unusual 
air-pressure  is  not  produced  within  it  or  accumulating 
secretions  cease  to  distend  it.  A  perfect  restoration  of 
a  dilated  bronchus  to  its  natural  shape  and  size  never 
takes  place. 

The  chronic  inflammation  within  a  cavity-  can  be 
treated  by  drugs,  as  chronic  bronchitis  always  is.    There 


60  Diseases  of  the  Bronchi. 

is  no  specific  medicinal  treatment  for  it.  The  objects 
should  be  to  prevent  increased  air-pressure  within  the 
lungs,  the  accumulation  of  secretions  in  the  cavities, 
and  the  extension  of  ulceration.  The  first  of  these  is 
best  accomplished  b}^  lessening  or  preventing  coughing, 
and  the  second  and  third  by  medication  which  will  lessen 
the  formation  of  secretions  and  of  suppuration. 


DISEASES  OF  THE  LUNGS. 


CHAPTER  lY. 

Emphysema. 
Anatomy. — Emph3'Sema  begins  with  a  dilatation  of 
infundibular  passages.  As  this  increases  the  alveoli 
enlarge,  their  walls  are  stretched  and  finall}'  torn.  Tlie 
infundibuliun  and  alveoli  are  tluis  converted  into  a 
single  small  cavit}",  which  by  gradual  inflation  becomes 
spheroidal.  Pin-head-sized  sacks  are  thus  formed.  If 
the  stretching  of  the  lung-tissue  persist  or  increase, 
the  elastic  fibres  in  the  infundibular  walls  atrophy  and 
the  walls  rupture,  and  neighboring  sacks  are  thus  made 
to  communicate  with  one  another  and  unitedly  form 
larger  cavities.  It  is  rare  that  the  cavities  are  larger 
than  a  pea  or  bean,  but  they  may  in  exceptional  cases 
be  much  larger.  These  anatomical  changes  are  neces- 
sarily accompanied  by  destruction  of  capillaries.  At 
first  the  capillaries  covering  the  alveoli  are  stretched 
and  narrowed.  Later  they  are  torn  and  destro3'ed. 
The  vascularity  of  the  emphysematous  tissue  is  greatly 
lessened,  so  that  it  is  pale  or  slightly  ros3\  The  vascu- 
lar changes  lead  to  less  and  less  perfect  nutrition  of  the 
tissue,  which  in  consequence  becomes  weaker  and  more 
easil}^  stretches  and  tears.  Prolonged  stretching  of 
the  elastic  fibres  leads  to  a  loss  of  elasticit}'  in  them. 
The  dilated  alveoli  therefore  have  gradually  less  ten- 
dency to  contract  strongly,  and  to  assume  a  natural 
form,  and  to  fulfil  their  function  of  emptj^ing  the  lungs 
of  air  that  has  been  utilized  in  them. 

(61) 


62  Diseases  of  the  Lungs. 

The  lesion  of  empliysema  may  be  unilateral  or  bilat- 
eral in  distribution,  circumscribed  or  diffuse.  The 
anterior,  median,  and  lower  borders  of  the  lungs  are 
oftenest  affected,  and  the  upper  lobes  oftener  than  the 
lower.  The  deep  lung-tissue  is  rarel}'  emphysematous. 
The  lesion  is  almost  confined  to  tlie  superficial  portion. 

Emph3'sema,  when  it  is  extensive  or  generalized, 
makes  the  lungs  unusually  voluminous.  Distension  of 
the  anterior  and  lower  borders  causes  tiie  lung  to  cover 
more  or  less  completel}-  the  pericardium,  to  separate  it 
from  the  chest-wall,  and  to  depress  the  heart  and  liver. 
When  the  thoracic  cavity  is  opened  emphysematous 
lungs  do  not  collapse.  An  incision  in  them  will,  how- 
ever, permit  the  air  to  escape.  The  surface  is  unusually 
dry.  The  lungs  when  compressed  creak  little  or  none. 
From  the  cut  ends  of  bronchial  tubes  muco-purulent 
matter  can  be  expressed,  for  bronchitis  more  or  less 
severe  and  extensive  accompanies  emphysema.  Other 
lung-lesions  are  frequentl}^  present,  as  emph3'sema  is  a 
secondary  one.  When  the  enlarged  lungs  crowd  the 
heart  downward,  the  diaphragm  may  be  simultaneously 
depressed ;  therefore,  the  liver  and  abdominal  viscera 
may  be  pushed  downward. 

Causes. — It  is  probable  that  eniph3'sema  can  be  pro- 
duced in  several  wa3's.  If  a  lung  is  not  property 
nourished  it  becomes  weak  and  emphysema  is  easil3'' 
developed.  This  b3'  man3'  observers  is  claimed  to  be 
the  most  important  factor  in  forming  the  lesion.  When 
emph3'sema  is  generalized,  as  in  old  age,  it  un- 
doubtedly is  the  most  potent  factor.  When  it  is 
circumscribed  it  is  chiefly  the  result  of  influences 
acting  mechanically.  For  example,  in  capillary  bron- 
chitis the  muco-purulent  plugs  which  mny  obstruct  the 
l)ronchioles    permit   air  to    enter   the    infundibula  and 


Emphysema.  63 

alveoli,  but  as  the  ex[)irjitory  act  is  less  forceful  than 
the  inspira.tory  they  do  not  permit  them  to  be  emptied. 
Tlie  alveoli  thus  gradually  become  disteuded.  When 
emphysema  is  compensatory  it  must  also  be  the  result 
of  mechanical  influences  only. 

Emphysema  is  of  very  frequent  occurrence  in  the 
aged.  In  them  the  lungs  are  not  increased  in  volume, 
but  the  alveoli  are  distended.  It  occurs  oftenest  in 
men.  It  is  observed  occasionall}'  in  successive  genera- 
tions of  a  family,  but  this  is  probably  a  coincidence,  and 
not  evidence  of  its  heredity.  Severe  coughing  is  a 
common  cause  of  it.  By  coughing  the  air  within  the 
lungs  is  placed  under  unusual  pressure,  which  of  neces- 
sity stretches  the  lung-tissue.  If  coughing  is  frequent, 
chronic,  and  severe,  it  is  especially  apt  to  produce 
emphysema.  The  severe  cough  of  pertussis  or  of  chronic 
bronchitis  may  cause  it.  Small  areas  of  emphysema  are 
not  uncommon  in  phthisis.  Bronchiolitis,  particularly 
if  it  is  subacute  or  chronic,  is  especially  liable  to  cause 
it.  If  one  lung  or  one  lobe  is  compressed  or  consoli- 
dated and  rendered  useless,  the  opposite  lung  or  neigh- 
boring lung-tissue  will  become  distended  and  emph}-- 
sematous. 

Symjjtoms, — If  emphysema  is  circumscribed.,  often  it 
cannot  be  detected  by  examination  of  the  chest  before 
death.  If,  as  frequently  happens,,  the  anterior  and  lowef 
borders  only  are  distended,  no  subjective  symptoms  may 
be  produced,  but  physical  examination  wnll  reveal  a 
diminished  area  of  cardiac  dullness,  depression  of  the 
liver,  absence  of  apex-beat  and  distant  cardiac  sounds, 

If,  however,  the  emphj^sema  is  generalized,  the 
ph3'sical  signs,  as  well  as  the  subjective  symptoms,  are 
striking  and  distinctive.  The  thorax  is  abnormally  em 
larged.     Its  lateral  diameter  is  greater  than  is  natural. 


64  Diseases  of  the  Lungs. 

The  antero-posterior  diameter  is  increjised  less.  The 
spine  is  arched  backward  and  the  sternum  forAvard.  The 
centre  of  the  tliorax  especially  is  distended.  This 
gives  to  the  entire  chest  a  barrel-shaped  appearance. 
The  intercostal  spaces  are  constantly'  stretched,  and  the 
whole  thorax  maintains  permanentl}'  the  position  of 
deep  inspiration.  The  acts  of  inspiration  and  expiration 
are  performed  by  lifting  and  lowering  the  whole  chest 
by  the  unusual  muscles  of  respiration.  The  unusual 
work  thus  given  to  the  sterno-cleido-mastoid,  and  other 
respirator}^  muscles  which  are  rarely  used,  causes  their 
hypertroph3\ 

Yocal  fremitus  is  diminished,  especialh^  in  advanced 
life,  when  the  thorax  becomes  rigid  and  the  costal  carti- 
lages ossified.  On  percussion,  the  area  of  pulmonary 
resonance  is  found  to  be  permanentl}^  increased.  The 
area  of  cardiac  dullness  is  diminished  or  absent.  The 
lower  borders  of  the  lungs  remain  distended,  and  the 
line  of  resonance  does  not  move  with  the  respiratory 
movements  as  it  does  in  health.  Vesicular  murmurs 
are  feeble  or  wanting.  In  man}-  cases  the  crowing  and 
piping  sounds,  which  are  caused  by  the  coincident 
bronchial  inflammation,  obscure  all  others. 

The  apex-beat  of  the  heart  is  invisible  and  usually 
cannot  be  felt.  The  cardiac  sounds  are  not  as  loud 
as  normal,  especially  at  the  apex.  The  second  sound 
over  the  jmlmonar}'  orifice  is  accentuated  in  cases  of 
chronic  emphysema.  This  is  due  to  obstruction  to  the 
pulmonary  circulation  which  the  destruction  of  capilla- 
ries causes.  Cardiac  murmurs  are  rarel}^  developed, 
but  if  they  exist  they  are  due  to  dilatation  of  the  heart. 

The  most  prominent  subjective  symptom  is  dyspnoea. 
It  is  wanting  in  mild  cases  and  when  the  lesion  is  circum- 
scribed  but  is  often  very  great.     The  vital  capacity  of 


Emphysema.  65 

the  lungs  is  greatly  lessened  ;  therefore,  less  oxygen  is 
furnished  to  the  blood.  The  destruction  of  pulmonary 
capillaries  also  interferes  with  the  blood's  aeration. 
These  are  the  important  causes  of  dyspnoea.  The  ex- 
piratory power  is  greatly  lessened,  because  of  the  im- 
mobility of  the  ribs  and  loss  of  lung  elasticity. 

Whenever  dyspnoea  is  great  cyanosis  develops.  It 
is  rare  that  the  causes  of  dyspnoea  just  mentioned  are 
sufficient  to  produce  much  cyanosis;  but, if  bronchiolitis 
is  extensive  and  the  tubes  much  obstructed,  it  is  com- 
mon ;  or,  if  the  heart-muscle  become  weak  and  passive 
engorgement  develops,  it  is  very  evident.  Death  usually 
is  caused  b^^  oedema  of  the  lungs  or  heart-weakness. 

The  disease  has  an  indefinite  duration.  If  not 
severe  it  does  not  much  interfere  with  life-work,  but 
when  severe  causes  chronic  invalidism.  In  itself  it 
rarely  leads  to  fatal  results,  though  it  increases  very 
greatly  the  danger  to  life  when  other  diseases  attack  its 
victims.  The  prognosis,  therefore,  depends  upon  the 
nature  and  severity  of  accompan^^ing  diseases. 

Ti-eatment. — The  causes  of  emphysema  should  be 
removed  whenever  possible,  and  if  it  has  not  been  of 
too  long  standing  recovery  then  becomes  probable. 
Many  cases  of  bronchitis  which  cause  it  are  curable. 
Compression  of  the  luug  from  pleural  effusions,  which 
provoke  emphysema  of  the  opposite  lung,  is  often 
capable  of  relief.  Manj^  other  causes  of  it  are  remov- 
able. 

The  treatment  of  chronic  cases  must  embrace  a  care- 
ful regulation  of  habits,  so  that  as  good  general  health 
can  be  maintained  as  possible.  Tonics,  such  as  strych- 
nia and  quinine  and  iron,  are  invaluable  whenever  tissue 
enfeeblement  or  degenerative  changes  are  prominent 
factors  in  the  causation  or  maintenance  of  the  lesion. 


66  Diseases  of  the  Lungs. 

They  must  be  eniplo3'ed  for  long  periods  of  time.  The 
best  results  are  nsuiilly  obtained  by  occasional  changes 
in  the  preparations  which  are  used.  Iodides  do  much 
good  when  chronic  bronchiolitis  is  the  cause  of  the 
emphysema. 

Chronic  emphysema  of  long  standing  results  iu  an 
absolute  loss  of  elasticity  in  the  affected  [)ortions  of  the 
lungs,  and  a  degree  of  alveolar  and  capillary  destruc- 
tion which  is  irreparable.  Iu  cases  less  in  degree  and 
duration  the  elasticit}^  can  largely  be  restored  by  train- 
ing the  luugs  to  contract  and  ex[)and.  This  can  be 
accomplished  hy  pneumatic  apparatuses  of  vnrious 
kinds.  Exhalation  into  rarefied  air  will  cause  partial 
collapse  of  the  alveoli  b\'  withdrawing  from  the  lungs 
an  unusually  large  amount  of  their  contents.  By 
repeated  exhalations  of  this  kind  the  lungs  are  made 
forcibly  to  contract  and  expand  to  a  normal  extent,  and 
gradually  a  habit  of  approximately  normal  respiration 
can  be  acquired.  Yery  great  temporary  relief  to  dysp- 
noea can  always  be  obtained  in  this  way.  As  the  loss 
of  lung  elasticity  is  largel}'  the  cause  of  the  prolonged 
distension,  considerable  relief  is  often  obtained  by 
wearing  continuouslj'  a  broad  elastic  band  about  the 
thorax.  It  gradually  increases  the  force  and  deepens 
expiration,  and  thus  enlarges  the  vital  capacit}'  of  the 
chest. 


CHAPTER  y. 

Atelectasis. 

Anatomy. — The  part  of  the  Imig  which  is  collapsed 
is  usually  depressed  below  the  surface  of  the  rest,  is 
angular,  uueven,  and  brownish  or  l)luish  red.  If  the 
atelectasis  is  of  long  duration,  it  ma}'  be  grayish  in 
color.  An  entire  lung  may  be  colla[)sed,  but  iu  most 
cases  a  part  only  is  affected.  The  atelectatic  portion  is 
hard,  and  feels  fibrous  when  the  lesion  is  chronic.  It  is 
leathery  or  brittle.  It  does  not  crepitate.  If  com- 
pressed, no  air  can  be  squeezed  from  the  cut  surface, 
although  mucous  generally  can  be  from  the  bronchi. 
The  affected  tissue  sinks  in  water.  At  first,  the  alveoli 
appear  smaller  than  normal,  more  anguhir,  and  some- 
times quite  flattened.  The  capillaries  are  usually  visible 
as  swollen  and  tortuous  vessels.  Later  on,  the  epithe 
lial  cells  are  loosened  from  the  alveolar  walls,  and 
degenerate.  The  connective  tissue  is  thickened  by 
h3'perplasia  of  its  cells.  The  capillaries  become  less 
swollen,  and  the  outlines  of  the  alveoli  less  evident, 
because  more  and  more  collaiised  and  contracted.  On 
account  of  these  cirriiotic  changes  the  capillaries  are 
less  permeable,  and  the  increased  blood-tension  thereby 
produced  in  the  pulmonary  artery  leads,  in  extensive 
and  chronic  cases,  to  h^'pertrophj^  of  the  right  ventricle. 

Cause. — Atelectasis  is  commonly  caused  in  four 
ways  :  1.  It  is  congenital.  Tiie  aflTected  lung  or  por- 
tion is  then  uninflated.  This  condition  maj-  graduall}' 
be  corrected,  or  remain  a  permanent  one.  It  occurs 
oftenest   in   premature,   prolonged,  or   difficult   births. 

(67) 


68  Diseases  of  the  Lungs. 

2.  It  is  due  to  absorption  of  the  air  from  the  alveoli. 
This  occurs  oftenest  when  the  small  bronchi  are  ob- 
structed by  mucous  plugs,  the  result  of  bronchiolitis. 
Fresh  air  cannot  enter  the  obstructed  tube,  and,  there- 
fore, the  air  that  is  held  in  the  un ventilated  alveoli  is 
slowly  absorbed  b}^  the  blood.  The  oxygen  is  first 
taken  up,  and  then  tlie  carbonic-acid  gas  and,  later,  the 
nitrogen.  Obstruction  of  large  bronchi  b}^  swollen 
lymph-glands,  tumors,  etc.,  which  rarel}'  occurs,  is  also 
followed  by  absorption  atelectasis.  3.  Compression 
atelectasis  is  usually  due  to  pleuritic  effusion,  pneumo- 
thorax, tumor  of  the  pleura  and  lung,  rarely  to  pericar- 
dial effusion,  dilated  heart,  or  aneurisms.  Other  causes 
are :  mediastinal  growths,  deformit}^  of  the  thorax, 
abdominal  tumors,  and  ascites.  4.  The  last  form  is 
known  as  marasmatic  atelectasis.  It  is  the  result  of 
the  great  debility  which  is  produced  by  wasting  dis- 
eases, such  as  tuberculosis  and  typhoid  fever. 

Congenital  atelectasis  usually-  occurs  in  the  base  of 
the  lungs  ;  not  ver}^  unfrequentl}'  in  the  anterior  lower 
borders,  and  rareh'  at  the  apices.  Absorption  and 
marasmatic  atelectasis  also  occurs  oftenest  in  the  lower 
part  of  the  lungs.  The  part  affected  in  compression 
atelectasis  depends  entirely  upon  the  location  and  char- 
acter of  the  cause. 

Symptoms. — If  congenital  atelectasis  is  extensive, 
the  child  will  breathe  superficial!}',  and  with  unusual 
rapidit}-.  Often  a  soft,  murmuring  noise  is  produced  by 
respiration.  The  child  will  refuse  the  breast.  Its  face 
will  be  gray  or  livid,  the  pulse  quick  and  weak.  Death 
may  result  from  suffocation.  Twitchings  and  even  con- 
vulsions often  precede  the  termination  of  life.  .If  the 
collapsed  areas  are  extensive,  the  lung  and  even  the 
thorax  may  be  retracted,  but  tiiey  are  rarely  of  sufficient 


Atelectasis.  69 

size  to  cause  dullness  on  percussion,  bronchial  breathing, 
or  other  signs  of  consolidation. 

In  acquired  atelectasis  the  sj-mptoms  are  the  same 
ill  kind,  but  they  are  frequent]}-  transitory,  as  compen- 
satory emphysema  usually  accompanies  them.  When 
collapse  first  occurs,  fine  crepitant  rales  can  be  heard. 
If  the  air  has  only  been  partly  removed  from  the  affected 
parts,  t3'mpanitic  resonance  may  be  audible.  If  the  air 
is  altogether  absorbed,  and  the  area  is  at  least  one  and 
one-half  inches  in  surface-area  and  two-thirds  of  an  inch 
in  thickness,  dullness  can  be  detected,  and  broncho-vesic- 
ular or  in  larger  areas  bronchial  breathing  and  increased 
vocal  fremitus  can  be  heard.  If  the  conditions  are 
present  which  lead  to  hypertrophy  of  the  right  ventricle, 
the  second  sound  over  the  pulmonary  artery  will  be  ac- 
centuated. Percussion  ma}-  demonstrate  enlargement 
of  the  heart  to  the  right,  and  substernal  pulsations  will 
be  evident. 

Ty^eatment. — If  the  cause  of  atelectasis  can  be  re- 
moved, deep  breathing,  pulmonary  gymnastics  or  inhala- 
tions of  compressed  air  may,  singly  or  combined,  re- 
expand  the  collai)sed  tissues,  but  if  the  collapse  has 
lasted  long  enough  to  have  caused  cirrhotic  changes  and 
ol)literation  of  the  alveoli,  recovery  is  impossible.  If 
the  atelectatic  areas  are  not  too  large,  emphysema  may 
fully  compensate  for  them. 


CHAPTER  VI. 

HiEMORRHAGIC    INFARCTION. 

Causes  and  Anatomy. — Hemorrhagic  infarcts  in  the 
lungs  are  possible,  because  the  puhnonar}^  arterioles  are 
terminal.  An  embolus,  which  will  produce  them,  may 
be  derived  either  from  the  veins  of  the  bod}^  or  from  the 
right  side  of  the  heart.  Fibrinous  clots  are  not  uncom- 
monly formed  in  the  right  ventricle  when  it  is  dilated, 
and  in  the  veins  when  they  are  inflamed.  The  infarcts 
may  form  in  an}^  part  of  the  lung,  but  they  are  oftenest 
observed  near  the  surface  and  in  the  lower  part. 

If  an  embolus  obstruct  an  arteriole,  the  circulation 
will  cease  beyond  it.  The  pressure  is,  therefore,  nothing 
in  the  artery  beyond  the  obstruction.  The  blood  now 
flows  back  into  the  arterioles  from  the  capillaries,  and 
even  from  the  veins,  and  engorges  the  area  supplied  bv 
the  obstructed  artery.  The  blood  extravasating  into  the 
pulmonary  tissue  and  alveoli  consolidates  the  lung  at 
this  point.  The  solid  mass  is  conoidal,  with  an  apex  at 
the  point  of  embolism  and  base  usualh'  at  the  pleura. 
Infarcts  vary  in  size  from  a  cherr\'-stone  to  a  hen's  egg, 
and  rarely  are  larger.  .They  can  usuall}-  be  seen  through 
the  pleura  as  dark,  purplish,  slightly  raised  masses, 
which  feel  Arm  to  the  touch.  The  pleural  surface  is 
usually  congested  and  covered ^with  more  or  less  fibrin. 
When  cut  through,  tiie  conical  sha[)e  of  an  Infarct  be- 
comes evident.  At  first  its  surface  is  purplish  red.  If 
resolution  take  place  it  becomes  i-eddish  brown,  a  rusty 
color,  or  even  grayish,  with  an  excess  of  brownish-black 
pigment.  Under  the  microscope  there  is  seen  at  first 
(70) 


Hoemorrhagic  Infarction.  71 

only  a,  mass  of  blood  in  the  alveoli  and  lung-tissue.  If 
resolution  occur,  wlnte  cells  become  more  numerous 
and  the  red  ones  disintegrate,  and  thereby  form  pigment 
granules,  which  are  deposited  in  the  interstitial  tissues 
or  absorbed  into  it.  The  interstitial  tissue  is  thickened 
and  ^a  permanent  toughening  and  [)igmentation  of  the 
lung  results.  The  air  once  more  enters  the  air-cells,  but 
they  expand  and  contract  im[)errecth',  because  of  their 
thick  walls.  The  arterial  embolus  may  also  disappear, 
but  usuall}^  it  leaves  a  thickening  of  the  arter^^'s  wall  at 
the  point  of  embolism.  The  permanent  pigmentation 
gives  the  cirrhosed  tissue  a  brown  or  slate  color.  If 
resolution  is  delayed,  and  especially  if  the  infarct  is 
large,  a  part  of  the  lung-tissue  maj^  be  destroyed,  being 
liquefied  and  converted  into  an  odorless,  brown  i)ulp. 
This  either  finds  its  way  into  a  bronchus  and  is  expec- 
torated, or  it  is  absorbed  and  the  cavity'  obliterated  by 
cicatriziition.  In  rare  cases  the  cells  and  the  tissue  in- 
volved in  the  infarct  disintegrate  slowly,  dr}',  and  are 
transformed  into  a  caseous  and  cretaceous  mass,  which 
is  surrounded  by  a  librous  capsule.  If  the  embolus  con- 
tain p3'ogenic  matter  an  abscess  is  the  result.  Pleuritic 
adhesions  ma}^  form  over  infarcts. 

An  infarct  is  not  caused  whenever  there  is  an  embo- 
lism of  a  pulmonary  artery.  Sometimes  death  occurs 
before  it  can  be  produced.  Sometimes  collateral  cir- 
culation by  the  capillaries  or  communicating  arteries 
may  prevent  it. 

Sym])lomii. — Infarcts  may  exist  and  produce  no  symp- 
toms. Embolism  of  the  large  arteries  may  cause  sudden 
death,  or  when  this  does  not  happen  sudden  and  great 
dyspntiea  and  thoracic  oppression  may  be  felt.  The  most 
characteristic  symptom  is  haemo[)tysis.  Tiie  expectorate 
may  be  mixed  blood  and  mucus,  or  consist  almost  en- 


72  Diseases  of  the  Lungs. 

tirely  of  dark  blood.  Tlie  lisemovrliage  ma}*  last  a  few 
hours  onlj^  or  several  days.  Pleuritic  pains  ma}'  also  be 
felt.  If  the  infarct  is  small  or  deeply  seated,  physical 
examination  will  afford  no  positive  information.  Pleu- 
ritic friction-sounds  are  sometimes  heard.  If  the  infarct 
is  larger  and  superficial  it  may  produce  an  area  of  relative 
dullness  on  percussion,  and  crepitant  rales  or  bronchial 
respirator}'  sounds  may  be  audible  over  it.  Fever  ma}' 
be  absent  or  present.  A  diagnosis  will  depend  upon  the 
existence  of  a  cause  for  embolism  of  the  lungs  and  upon 
the  occurrence  of  haemoptysis.  The  prognosis  depends 
upon  the  primary  disease,  the  strength  of  the  patient, 
and  character  of  the  embolus.  If  the  malady  complicates 
heart  disease  it  is  rather  unfavorable,  for  it  signifies 
weakness  of  the  right  ventricle. 

Treatment. — When  the  causes  of  embolism  of  the  lung 
exist,  bodily  rest  is  essential  for  its  prevention.  Treat- 
ment must  be  symptomatic.  Pleuritic  pains  may  neces- 
sitate the  use  of  anodynes.  The  primary  disease  re- 
quires special  treatment.  Resolution  is  best  assured  by 
removing  the  primary  disease  and  maintaining  a  good 
circulation  and  good  general  nutrition. 


CHAPTER  YII. 

Hypostatic  and  Passive  Congestion. 

Causes  of  Hypostatic  Congestion. — Hypostatic  con- 
gestion is  a  secondary  lesion  of  frequent  occurrence. 
It  develops  when  the  venous  circulation  through  the 
lungs  is  impeded  by  an  enfeebled  heart's  action,  and 
when,  through  the  prolonged  retention  of  one  position, 
the  blood  stagnates  in  the  veins.  It  is  the  prolonged 
retention  of  the  recumbent  posture  that  usuall}'  causes 
it  to  develop  in  the  posterior  and  lower  part  of  the 
lungs.  The  enfeebled  heart  is  oftenest  the  result  of 
wasting  illness,  such  as  typhoid  fever  and  suppuration. 
Fractures  and  paralysis  may  also  cause  the  essential 
weakness  and  dorsal  decubitus.  Impediments  to  respi- 
ration, such  as  pleuritic  adhesions  and  thoracic  de- 
formit}',  or  compression  of  the  lungs  by  distension  of 
the  abdomen,  increase  the  tendency  to  hypostatic  con- 
gestion. 

The  capillaries  and  veins  are  distended,  and  impart 
to  the  affected  tissue  a  purplish  and  often  almost  a  black 
hue.  The  alveoli  are  filled  with  serum.  A  few  blood- 
corpuscles  find  their  way  into  them.  The  epithelial 
cells  are  cast  off  and  become  granular.  If  the  lesion  is 
quite  persistent  the  alveoli  contain  large  numbers  of 
these  cells,  and  closely  resemble  those  consolidated  by 
catarrhal  pneumonia.  Under  such  conditions  the  lungs 
become  heavy  and  firm.  They  do  not  crepitate.  Atelec- 
tasis and  pulmonar}"  oedema  are  often  associated  with 
hypostatic  congestion. 

Symptoms. — This    lesion    may  persist   for   days   or 

4    D  (73) 


*r4  Diseases  of  the  Lungs. 

weeks,  or  disappear  in  a  few  hours.  It  is  readil}'  over- 
looked if  attention  is  concentrated  too  closel}'  on  tlie 
primary  disease.  In  diseases  in  which  it  often  occurs 
(especiallj-  typhoid  fever)  it  should  be  guarded  against 
and  watched  for.  Frequently  rapid  respiration  is  the 
onl}'  symptom  which  suggests  its  existence.  If  the 
lesion  is  extensive  it  may  cause  cyanosis.  Cough  is 
not  often  present ;  when  it  is  it  may  be  accompanied  bj- 
a  mucous,  muco-purulent,  or  even  purulent  expectorate. 
Fever  is  not  caused  by  hypostatic  congestion  unless  in- 
flammation supervenes.  Percussion  over  the  posterior 
thoracic  surface  will  usually  at  first  give  a  tympanitic 
resonance,  because  of  the  relaxed  condition  of  the  lung. 
In  more  chronic  eases  various  degrees  of  dullness  exist. 
At  first  fine,  moist  rales  are  heard,  and  the  respiratory 
sounds  are  often  feeble.  Later  the  sounds  become  bron- 
chial and  consonant.  Increased  vocal  fremitus  is  then 
demonstrable.  These  physical  signs  are  those  of  con- 
solidation of  the  lung,  and,  therefore,  the  same  as  those 
of  pneumonia.  It  is  to  be  distinguished  from  the  latter 
disease  chiefl}-  by  the  history  of  its  development,  its 
secondary  character,  and  by  its  usual  bilateral  distribu- 
tion. (Edema  rareh"  produces  consolidation,  and  usually 
causes  the  rales  to  be  more  widelj'  diffused.  A  positive 
diagnosis  is  at  times  impossible.  The  prognosis  is  grave, 
though  by  no  means  hopeless. 

Treatment. — The  most  successful  treatment  is  prophy- 
lactic. It  consists  in  frequently  shifting  the  patient  from 
side  to  side,  and  thus  preventing  the  gravitation  of  blood 
to  an}'  one  part  of  the  lungs  ;  and  in  administering  a 
cardiac  tonic,  such  as  digitalis.  In  febrile  cases  spong- 
ings  and  baths  maintain  a  better  periplieral  circulation, 
by  creating  a  greater  degree  of  arterial  tone,  in  conse- 
quence of  which  a  better  balance  is  maintained  between 


Hypostatic  and  Passive  Congestion,  T5 

the  arterial  and  the  venous  blood.  When  the  lesion  is 
once  established  the  same  care  must  be  maintained  to 
prevent  its  increase.  But  the  carbonate  and  chloride 
of  ammonium  are  now  useful,  both  as  cardiac  stimulants 
and  as  expectorants,  if  there  is  an  accompanying  bron- 
chitis. Counter-irritants  will  temporarily  relieve  the 
congestion  when  it  first  occurs. 

Causes  and  Anatomy  of  Passive  Congestion. — Brown 
induration,  or  chronic  venous  h^-peraemia,  is  difficult  to 
diagnose  with  certaiut}'.  It  may  be  suspected  whenever 
there  is  much  dyspnoea  accompanj'ing  heart  diseases. 
It  is,  however,  only  one  of  several  factors  causative  of 
dyspnoea.  Wlien  the  lungs  are  examined,  the  pleural 
snrface  is  usually,  at  least  in  places,  reddish  purple,  and 
the  interlobular  septa  are  evident,  because  they  are  pig- 
mented by  a  dark-brown  coloring  matter.  Generally 
slight  emphysema  exists  here  and  there.  The  lungs  feel 
hard  and  dense,  especiallj'  in  places,  and  raostl}'  about 
their  bases.  The  cut  surface  permits  a  reddish-brown 
fluid,  mixed  with  air,  to  exude.  It  is  redder  than  nor- 
mal, though  not  bright,  but  a  brick-red.  The  pleura  and 
interlobular  septa  are  unusually  thick  and  contain  much 
of  the  red  pigment.  Under  the  microscope  the  alveolar 
walls  are  seen  to  be  unusuallj^  thick.  The  capillaries 
are  enormously-  distended  and  very  tortuous.  Their 
walls  are  thick.  The  blood-corpuscles  completel}^  fill 
them.  In  the  alveoli  there  are  man}^  red  corpuscles  and 
large  cells,  which  contain  large  granules  of  golden-brown 
pigment.  In  the  alveolar  walls  the  same  pigment  can 
be  seen,  but  usuall3Mt  is  a  little  darker  in  color.  Where 
the  lungs  are  most  dense  the  alveoli  are  most  filled  with 
such  cellular  contents. 

This  lesion  is  developed  by  a  venous  stasis,  which, 
slowly  dilating  the  veins  and  then  the  capillaries,  causes 


76  Diseases  of  the  Lungs. 

finall3'  a  moderatel}'  copious  serous  exudation  in  the 
alveoli,  and  some  haemorrhage.  It  is  thus  that  the  red 
corpuscles  and  serum  are  expressed  into  the  alveoli. 
The  epithelium  is  soon  detached  and  almost  wholly 
lost.  The  white  corpuscles  take  up  the  pigment-gran- 
ules which  are  formed  by  the  disintegration  of  the  red 
cells.  The}'  increase  in  size,  and  thus  form  the  large 
pigmented  cells  that  have  been  described  as  a  part  of 
the  contents  of  the  alveoli.  Some  of  the  pigmented 
cells  find  their  way  into  the  lymph-channels  and  deposit 
in  them  their  coloring  matter  Minute  hsemorrhages 
from  which  pigment  is  formed  occur  in  the  pleura  and 
interstitial  tissues.  The  small  bronchi  are  greatly  con- 
gested. The  walls  of  the  distended  vessels  are  thick- 
ened. The  mucous  membrane  is  somewhat  swollen,  and 
man}'  epithelial  cells  are  loosened. 

Symptoms. — The  changes  in  the  bronchi  and  conges- 
tion of  the  alveolar  vessels,  which  dimiuishes  the  air- 
spaces in  the  lungs,  are  important  factors  in  producing 
dyspnoea.  The  partial  filling  of  the  alveoli  with  serum 
and  cells  diminishes  the  lung-capacit}'.  The  slow  and 
imperfect  pulmonar}-  circulation  causes  a  lessened  oxi- 
dation of  the  blood,  and  also  contributes  to  produce 
dyspnoea. 

Anything  that  obstructs  the  pulmonary  vein  may 
cause  this  lesion.  All  forms  of  valvular  disease  of  the 
heart  ma}^  do  it,  but  oftenest  it  is  a  mitral  stenosis  that 
does.  It  is  a  peculiar  and  not  well-explained  fact,  that 
in  one  case  brown  induration  will  be  developed  to  the 
fullest  extent,  and  in  another,  with  apparently  the  same 
causes  and  conditions  present,  it  will  not  exist.  Often, 
in  these  cases,  exaggerated  or  puerile  respirator}'  sounds 
are  heard  during  life.  If  the  large  pigmented  cells  can 
be   found    in   the   sputa,  a    positive   diagnosis   may  be 


Hypostatic  and  Passive  Congestion.  77 

made.  Red  blood-cells  are  also  sometimes  seen  in  the 
sputa.  The  pigmented  and  blood  -cells  rarely  color  the 
expectorate. 

The  prognosis  depends  upon  the  primary  heart- 
lesion.  Treatment  must  be  addressed  entirely  to  the 
latter. 


CHAPTER   YIII. 

Pulmonary  (Edema. 

Anatomy. — The  anatomical  clianges  which  are  char- 
acteristic of  oedema  of  the  lungs  are  enlargement  of 
them  and  increase  in  weight.  The}'  are  often  very  pale 
in  color,  but  the}'  may  be  congested.  The}'  do  not  col- 
lapse when  the  thoracic  cavity  is  opened.  When  pressed 
between  the  fingers  pits  remain,  as  they  do  in  other 
cedematous  tissue.  When  a  lung  is  incised  an  abun- 
dance of  serous  fluid  flows  from  it,  which  is  usually 
colorless,  ])ut  may  be  either  pink  or  red,  according  to 
the  degree  of  congestion  that  exists.  The  fluid  may 
or  may  not  be  frothy.  When  only  a  part  of  a  lung  is 
involved  in  oedema,  it  is  the  most  dependent  part.  If 
circumscribed  inflammation  of  the  lung — as  croupous 
pneumonia — exist,  it  is  often  found  to  be  bordered  by 
a  zone  of  cedematous  tissue. 

Symptomii. — The  symptoms  of  oedema  of  the  lungs 
which  are  of  diagnostic  value  are  not  developed  unless 
the  oedema  is  considerable  in  degree.  (Edema  is  often 
the  immediate  cause  of  death.  It  may  develop  with 
great  rapidity  and  produce  fatal  results  in  a  few  hours, 
or  may  develg)p  more  gradually.  When  oedema  is  the 
outgrowth  of  other  lesions  of  the  lungs,  pathognomonic 
symptoms  are  often  wanting.  (Edema  of  the  lungs 
does  not  cause  fever. 

Persistent  dyspnoea  is  one  of  the  most  striking- 
symptoms  which  it  produces.  As  it  becomes  greater, 
cyanosis  develops.  The  lips  and  finger-nails  become 
purplish,  and  the  skin  ashen,  usually  cool,  and  bathed 
(78) 


Pulmonary  (Edema.  79 

with  perspiration.  Coughing  occurs  with  more  or  less 
frequenc}',  and  considerable  or,  sometimes,  very  large 
quantities  of  serous  fluid  are  expectorated,  which  ma}'' 
or  may  not  be  frothy,  pink  or  colorless.  The  abundant 
expectoration  usually  does  not  .continue  long,  for,  as  the 
lungs  become  more  and  more  comi)letely  filled  and  the 
blood  cyanotic,  mental  dullness  develops,  which  grad- 
ually passes  into  somnolence.  This  hebetude  causes  a 
cessation  or  diminution  in  the  frequency  and  strength 
of  the  cough.  Under  such  circumstances  the  fluid 
gathers  in  the  throat  and  causes  a  coarse  rattle  there. 
Respiratory  movements  become  more  and  more  shallow, 
then  a  little  irregular,  and  finally  they  cease. 

If  a  physical  examination  of  the  chest  is  made,  the 
respiratory  movements  will  be  observed  to  be  rapid  and 
shallow.  Unless  the  oedema  is  due  to  a  localized  inflam- 
mation which  is  in  one  lung  only,  the  respiratory  change 
will  be  found  alike  on  both  sides  of  the  chest.  This 
S3'mmetrical  distribution  of  physical  signs  is  especiall}' 
characteristic  of  the  oedema  which  accomi)anies  heart, 
renal,  and  general  diseases.  Palpation  reveals  no  ab- 
normalit}'.  Percussion  reveals  a  normal  resonance,  or, 
frequently,  a  semi-tj-mpanitic  resonance.  Moist  rales  are 
abundant.  At  first,  they  are  fine  ;  later,  coarse.  A  diag- 
nosis is  possible  onl^-  when  we  find  dNspnoea,  cyanosis, 
an  abundant  serous  expectoiate^  and  a  cause  for  oedema. 

Cannes. — Rnrel}',  cases  of  oedema  of  the  lungs  are 
observed  which  develop  rapidly,  and  for  which  no  ade- 
quate explanation  can  be  given.  They  are  sometimes 
termed  idiopnthic  oedema  of  the  lungs,  serous  apoplexy-, 
or  serous  pneumonia.  Exposure  to  cold  is  an  alleged 
cause,  but  we  have  not  positive  proof  that  it  is  one. 

Localized  inflammations  are  a  cause  of  circumscribed 
oedema,  which  occasional!}'  spreads  and  involves  an  en- 


80  Diseases  of  the  Lungs. 

tire  lung,  or  both  of  them.  This  happens  not  infre- 
quently in  cases  of  crupous  pneumonia,  and  oedema  then 
becomes  the  immediate  cause  of  death.  Often  pul- 
monary oedema  is  a  part  of  general  oedema,  such  as 
complicates  heart  and  renal  diseases.  Mitral-valve  dis- 
ease is  especially  apt  to  lead  to  pulmonary  oedema,  but 
all  cardiac  diseases  that  are  accompanied  bj^  dilatation 
of  the  heart  and  weakness  of  it  are  liable  to  precipitate 
oedema  of  the  lungs.  The  cardiac  weakness  which  re- 
sults from  prolonged  fever  or  other  wasting  disease  is 
frequently  the  cause  of  pulmonary  oedema.  The  lesion 
is  also  caused  b}^  the  paralysis  of  the  left  side  of  the 
heart,  which  occasionally-  occurs  just  prior  to  death. 
We  find,  then,  upon  post-mortem  examination,  oedema 
of  the  lungs,  although  no  symptoms  of  it  existed  prior 
to  death.  When  it  accompanies  renal  affections,  it  is 
due  in  part  to  an  enfeebled  circulation  and  in  part  to 
an  impoverishment  of  the  blood. 

Treatment. — The  most  successful  treatment  is  pro- 
phylactic, and  should  be  used  when  causes  of  oedema 
exist.  When  the  lesion  is  established,  especiall}'  if  it 
involve  the  lungs  extensively,  it  is  rarelj'  amenable  to 
treatment.  A  prognosis  in  such  cases  must  be  guarded, 
and  the  immediate  danger  to  life  recognized. 

Prophylactic  treatment  must  var\'  with  the  cause 
which  exists.  In  fevers  oedema  can  be  avoided  b}-  fre- 
quent changes  of  position  which  will  prevent  hj'postatic 
engorgement.  Cardiac  tonics,  such  as  digitalis  and 
str3'chnia,  should  be  administered  when  the  heart  is 
feeble  and  the  blood-vessels  relaxed,  to  counteract  these 
conditions.  Frequent  spongings  of  the  surface  of  the 
body  stimulate  tlie  circulation,  and  maintain  a  better 
tone  in  the  peripheral  vessels.  It  is  also  an  important 
aid  in  maintaining  a  good  general  circulation. 


Pulmonary  (Edema.  81 

In  cardiac  find  renal  diseases,  when  general  oedema 
is  extensive  and  pulmomuy  cedema  must  be  anticipated, 
diaphoresis,  dinresis,  and  catharsis  are  useful  modes  of 
treatment,  as  tliej'  lessen  the  general  oedema.  Heart 
tonics  are  usuall}'  necessar}-. 

In  the  so-called  idiopathic  cases  venesection  has 
been  found  to  do  temporary  good.  It  should  be  fol- 
lowed b^'  the  administration  of  digitalis,  strychnia,  and 
ero;ot, — ao;ents  which  will  maintain  a  vigorous  action  of 
the  heart  and  a  good  degree  of  vascular  tone. 

If  oedema  of  the  lungs  must  be  treated  after  it  has 
developed,  reliance  must  be  placed  upon  digitalis,  strych- 
nia, and  ergot.  I  have  seen  such  good  results  obtained 
from  the  inhalation  of  ox3'gen  in  these  cases  that  I  be- 
lieve it  should  always  be  tried  if  the  gas  can  be  obtained. 
During  the  last  winter  I  saw,  in  consultation,  a  woman 
just  delivered  of  a  child  and  simultaneously  attacked 
b}^  pneumonia.  In  a  few  hours  extensive  oedema  of  the 
lungs  developed  and  threatened  immediate  destruction 
of  life.  She  labored  severelj^  for  breath,  was  cyanotic, 
covered  with  cold  perspiration,  and  almost  pulseless. 
Oxygen  was  administered  b}^  inhalation  for  several 
minutes  every  half-hour.  The  cyanosis  disappeared, 
the  labored  breathing  lessened,  the  skin  became  warm, 
and  the  pulse  full,  firm,  and  stead3\  So  prompt  and 
decided  was  the  improvement  that  the  treatment  was 
persevered  in  and  life  undoubted!}'  prolonged  for  several 
days.  Ox3-gen  inhalations  will  undoubtedly  enable  us 
to  save  some  cases  that  would  otherwise  prove  fatal,  by 
maintaining  life  for  a  few  hours  or  da3^s,  until  a  turning- 
point  in  the  primary  disease  can  be  reached. 

4* 


CHAPTER  IX. 

Catarrhal  Pneumonia. 

Causes. — This  disease  raa}^  be  acute,  subacute,  or 
cbrouic  iu  its  course.  It  is  secondary  to  others;  most 
commonlj^  to  bronchiolitis.  It  is  a  frequent  complica- 
tion of  infectious  fevers.  Measles,  diphtheria,  influ- 
enza, and  whooping-cougb  are  complicated  by  it  with 
especial  frequenc^^  It  is  rare  exce[)t  in  childhood  and 
old  age.  Debilit}"  predisposes  to  it.  It  is  one  of  the 
usual  lesions  iu  chronic  tubercular  diseases  of  the  lung. 
Pneumonic  nodules  are  often  built  up  around  miliary 
tubercles. 

Anatomy. — Catarrhal  pneumonia  is  characterized  b}^ 
the  development  of  solid  nodules  Avhich  may  be  scat- 
tered through  the  lung.  They  var}'  in  size  from  a  pin- 
head  to  a  walnut.  Large  nodules  are  produced  by  the 
coalescence  of  the  smaller.  In  number  they  mny  be  few 
or  almost  countless.  They  are  most  frequentl}'  formed 
along  the  posterior  part  of  a  lung,  and  are  more  numer- 
ous at  the  base  nnd  gradually  less  toward  the  apex. 
When  they  exist  the  surface  of  the  lung  is  not  quite 
even.  The  superficial  nodules  cause  depressions  in  it. 
Over  the  nodules  there  is  often  pleuritic  inflammation. 
They  can  be  readily  felt  as  hard,  compact  bodies.  If  a 
section  is  made  through  one  it'  appears  purplish  in  the 
early  stages  and  grayish  3'ellow  later  on.  The  surface 
is  dry  and  granular.  The}'  contain  no  air,  but  a  yellow- 
ish or  brownish  fluid  can  be  scraped  from  them.  Around 
the  nodules  the  lung  is  often  slightl}'  emph3'sematous. 
A  bronchiole  forms  the  centre  and  focus  of  each  nodule. 
(82) 


Catarrhal  Pneumonia.  83 

From  it  a  muco-purulent  plug  can  be  squeezed.  Man}^ 
suppose  that  llie  iiiflaiiniiation  which  causes  the  nodules 
originates  from  drawing  into  tlie  lung  detritus  and  pus 
from  inflamed  bronchi  ;  otliers  believe  that  the  inflam- 
mation extends  by  continuit}'  from  the  bronchioles  to 
the  lung.  The  latter  seems  th.e  most  probable  ex- 
planation, although  the  lesion  may  at  times  be  produced 
in  both  waj^s. 

The  central  bronchiole  in  each  nodule  will  be  found 
to  be  filled  with  desquamated  epithelium,  granular  mat- 
ter, pus-cells,  and  mucus.  Its  wall  will  be  found 
thickened  and  infiltrated  with  round  cells.  The  adjoin- 
in":  alveolar  walls  are  similarly  aflJected.  Toward  the 
margin  of  the  nodule  the  alveolar  walls  are  less  and  less 
thickened.  At  first  the  alveoli  are  filled  with  serum  and 
the  capillaries  engorged,  but  soon  the  alveolar  epithelium 
becomes  granular,  is  cast  oflf,  and  helps  to  fill  the  air- 
cell.  Leucocytes  are  also  abundant,  especiall}'  in  the 
alveoli  nearest  to  the  central  bronchus.  Occasionall}' 
red  corpuscles  may  be  seen  forming  part  of  the  contents 
of  the  air-spaces.  They  are  usually  observed  in  the 
earlier  stages.  In  the  air-spaces  nearest  to  the  central 
bronchus,  fibrin  is  also  observable  when  consolidation 
first  occurs.  In  the  alveoli  at  the  periphery  of  thfe 
nodule  the  consolidation  is  due  almost  entirely  to  the 
abundant  and  closel3'-packed,  large,  oval,  epithelial  cells 
which  fill  them.  In  these  alveoli  the  process  is  purely 
a  catarrhal  one,  while  nearer  the  central  bronchus  the 
inflammation  is  accompanied  b}'  round-cell  infiltration. 

As  catarrhal  pneumonia  is  almost  uniformly  a  com- 
plication of  some  form  of  bronchitis,  the  anatomical 
changes  within  the  bronchi,  characteristic  of  their  in- 
flammation, are  to  be  expected  coincidentlj'.  The  pneu- 
monic nodules  may  undergo  resolution.     The  contents 


84  Diseases  of  the  Lungs. 

of  the  alveoli  will  be  absorbed,  and  complete  restoration 
may  take  place.  Instead  of  resolution  occasionally  the 
contents  of  the  alveoli  become  dr}",  the  cells  degenerate  ; 
finally,  the  alveolar  walls  degenerate,  and  the  whole  is 
transformed  into  a  fine,  hard,  drj^,  grayish,  chees}^  mass, 
which  may  remain  unchanged  indefinitely. 

Symptoms. — A  positive  diagnosis  is  often  impossible. 
Catarrhal  pneumonia  is  so  uniforml3'  a  complication  that 
it  is  frequentl^^  obscured  by  the  primar}^  disease.  It  is 
rare  tiuit  it  is  ushered  in  b\'  a  chill  or  an}-  other  noticeable 
phenomenon.  When  it  develops,  the  symptoms  of  the  pri- 
mary bronchitis  are  usually  intensified.  Cough  is  gen- 
erally drier,  often  more  painful,  and  occasionally  accom- 
panied by  slight  pleuritic  stitches.  Respiration  is  more 
rapid.  In  severe  cases  dvspnoea  is  marked,  and  C3'ano- 
sis  ma}'  develop.  General  prostration  is  great.  The 
temperature  is  higher  than  in  simple  bronchitis.  In  the 
latter  it  rarel}-  rises  to  103^  F.,  while  in  catarrhal  pneu- 
monia it  often  exceeds  this.  It  follows  no  definite  t3"pe, 
but  is  usuall}^  remittent,  the  morning  temperature  being 
nearly  or  quite  normal.  Deff'ervescence  takes  place 
slowl}'.  In  children,  breathing  is  often  painful,  and 
accompanied  by  moaning.  The  thorax  is  tender.  No 
characteristic  ph3'sical  signs  are  developed  unless  the 
nodules  coalesce  into  patches  of  at  least  two  inches 
superficial  area  and  of  two-thirds  of  an  inch  depth. 
Then  the  usual  evidences  of  consolidated  tissue  can  be 
found;  increased  vocal  fremitus,  bronchial  respiration, 
and  dullness  being  the  most  important  ones.  The  lesions 
are  usually  discoverable  in  both  lungs  at  the  same  time. 

A  probable  diagnosis  can  be  made  in  the  course  of 
bronchitis  if  the  temperature  is  abnormally  high,  the 
breathing  unusually  quick,  and  the  prostration  much 
greater  than  is  to   be   expected  from  acute  bronchitis. 


Catarrhal  Pneumonia.-  85 

If  the  chest  is  tender,  and  pleuritic  stitches  are  felt 
during  bre:i thing  or  coughing,  the  probability  is  still 
greater.  A  certainty-  in  tlie  diagnosis  can  be  felt  if,  in 
addition  to  these  symptoms,  patches  of  consolidation 
can  be  demonstrated. 

Tlie  disease  often  runs  a  ver}'  acute  course,  lasting 
only  a  few  hours,  or  two  or  tliree  days.  Frequentl}'  it 
pursues  a  subacute  course,  and  may  last  for  two  or  three 
weeks.  When  it  accompanies  measles,  it  is  inclined  to 
be  acute  ;  when  whooping-cough,  subacute. 

Treatmei}t. — The  treatment  is  the  same  as  would  be 
employed  in  cnpillary  bronchitis.  More  attention  must 
be  paid  to  the  maintenance  of  strength.  Food  in  its 
simplest  forms  must  be  administered  regularl3\  The 
heart's  streugtli  must  be  preserved  by  the  administra- 
tion of  digitalis,  strophanthus,  and  similar  tonics.  The 
carbonate  of  ammonia,  camphor,  and  other  diffusible 
stimulants  are  required  when  tlie  heart  flags.  The  rules 
for  their  administration  are  practically  tiiS  same  as  in 
treatment  of  ci'oupous  pneumonia.  (See  page  101.)  To 
stimulate  deeper  breathing  when  it  is  shallow  and  cya- 
nosis is  developing,  aid  can  be  derived  from  douches  and 
sponging  of  the  skin  of  the  bod3',  especitilly  with  alter- 
nating hot  and  cold  water.  Fomentations  so  prepared 
as  to  envelop  the  whole  chest  often  relieve  dyspnoea  and 
cough,  and  contribute  to  the  well  being  of  the  sufferer. 

The  prognosis  must  alwaj's  be  guarded,  and  the  dis- 
ease looked  upon  as  dangerous.  It  is  very  fatal :  from 
one  to  two-thirds  of  all  cases  die. 


CHAPTER   X. 

Croupous  Pneumonia. 

Nature  and  Causes. — Croupous  pneumonia  ma}'  be 
defined  as  a  fibrinous  inflammation  of  the  lungs,  afTect- 
ing  simultaneous]}'  large  areas  and  accompanied  b}' 
fever.  The  exact  nature  and  mode  of  causation  of  this 
disease  form  unsettled  questions.  It  resembles  closely 
an  infectious  disease,  and  without  much  doubt  is  one. 
As  in  other  infectious  diseases,  its  general  symptoms 
are  not  correlated  with  the  local  inflammation.  For  in- 
stance, the  fever,  often  the  delirium,  and  the  rapidit}'  of 
respiration  cease  suddenly,  and  before  consolidation 
has  disappeared  from  the  lungs.  It  also  resembles  them 
in  that  it  occurs  epidemicalh'  and  endemicall}-.  It  has 
rareh'  been  found  to  be  the  cause  of  death  in  infants  who 
are  born  while  their  mothers  are  suffering  fiH)m  it.  There 
is  also  much,  though  not  conclusive,  evidence  thnt 
micro-organisms  are  its  exciting  causes.  Several  micro- 
organisms are  capable  of  producing  fibrinous  inflamma- 
tion of  the  lungs.  Xo  one  form  is  found  to  unifornily 
accompany  pneumonia.  The  pneumococcus  of  Fried- 
lander  was  the  first  form  carefulh'  studied,  but  it  is  not 
observed  as  often  as  Fraenkel's  coccus.  Seibert  believes 
that  the  latter  is  tlie  usual  cause  of  sthenic  pneumonia, 
or  of  those  cases  that  run  the  classical  course,  and  that 
the  former  is  tiie  common  cause  of  those  which  run  a 
prolonged  and  more  typiioid  course.  Eichhorst  thinks 
that  secondary  pneumonias  are  not  the  result  of  super- 
imposed infection,  but  of  the  infectious  agent  of  the 
primarv  disease.  For  example,  that  in  tj'phoid  fever 
(86) 


Croujjous  Pneumonia.  87 

and  mensles,  the  cause  of  these  diseases  is  the  cause  of 
the  pneumouia  y\'hich  may  couiplicate  them.  It  must  l)e 
admitted,  however,  that  as  yet  our  knowledge  of  the  re- 
lationship oT  micro-organisms  to  crou[)ous  pneumonia  is 
not  definite.  It  is  probable  that  the  cases  now  known 
as  croupous  pneumonia  constitute  what  from  an  etio- 
logical stand-i)oint  might  be  regarded  as  sx'veral  dis- 
tinct diseases.  The  micro-organisms  supposed  to  cause 
croupous  pneumonia  are  frequentl}'  found  in  the  pleural, 
pericardial,  and  meningeal  exudates  that  result  from 
complicating  inflammations. 

Pneumonia  resembles  a  general  disease,  in  that  its 
course  is  cyclical,  that  its  general  symptoms  are  not 
correlated  to  the  local  ones,  and  that  it  is  endemic  and 
epidemic.  The  general  symptoms  are  undoubtedly^  due 
to  a  poisoning  of  the  system  by  some  chemical  substance 
or  substances  produced  by  the  local  inflammation  of  the 
lun2:s  or  the  micro-oroanism  that  causes  it.  In  this  re- 
spect  there  is  a  strong  analogy  between  the  disease  and 
typhoid  fever.  (See  Physiolog.  Act.  Typhoid  Poison, 
etc.)  What  may  be  the  nature  of  the  poison  or  poisons 
is  not  known.  The  recent  researches  of  Roger  and 
Gaume  upon  the  toxicit}^  of  the  urine  open  the  way  to  a 
better  knowledge.  The}^  found  that  during  the  period 
of  pneumonic  fcAcr  the  urine  contained  only  a  third  or 
fourth  as  much  of  toxic  matter  as  is  normal,  and  that  at 
the  time  of  crisis  it  suddenly  augmented  to  more  than 
normal,  or  at  least  to  the  normal  amount.  This  would 
suggest  that  the  poison  which  produces  the  general 
symptoms  is  not  eliminated  for  a  time,  and  that,  when 
it  is,  they  cease.  The  toxic  ingredients  of  the  urine  are 
certainh^  not  anj-  of  its  welhknown  constituents. 

Anything  that  lessens  vitality  predisposes  to  the  dis- 
ease.    Bad  h3'giene  and  debilit\'  from  other  kinds  of  ill- 


88  Diseases  of  the  Lungs. 

ness  are  predisposing  causes.  Excessive  use  of  alcohol 
not  only  increases  the  gravitA^of  the  disease,  but  greatl}^ 
augments  an  individual's  susceptibility  to  it. 

Pneumonia  occurs  in  all  parts  of  the  world.  The 
statement  has  been  general! \-  repeated  since  Drake  first 
made  it.  that  it  is  most  prevalent  in  the  southern  third 
of  this  coihitry,  and  least  in  the  northern  third.  By  a 
recent  review  of  statistics,  N.  S.  Davis,  Sr.,  has  found 
that  it  is  most  prevalent  in  the  middle  third  and  least  in 
the  southern. 

It  varies  much  in  prevalence  at  different  seasons. 
In  large  cities  it  is  endemic,  although,  at  least  in  the 
northern  cities,  primarv  croupous  pneumonia  is  rare  in 
summer.  In  Chicago,  and  other  cities  with  a  similar 
climate,  it  is  most  prevalent  from  December  to  Mai-ch, 
and  much  the  most  prevalent  in  December  and  Jan uaiy. 
Some  years  it  is  epidemic.  Its  severitj'  also  varies 
from  3'ear  to  year.  It  is  most  prevalent  during  or  im- 
mediately following  intense  and  penetrating  cold  weather. 
A  moist,  cold  air  will  provoke  an  increase  of  all  kinds 
of  respiratory  diseases. 

Individuals  in  everv  period  of  life  are  linble  to 
attacks  of  croupous  pneumonia.  It  is,  however,  most 
prevalent  during  3'outh  and  the  first  half  of  manhood, 
and  is  rare  in  infancy.  It  is  commoner  among  men 
than  women.  It  has  been  claimed  to  be  contagious,  but 
observations  are  not  numerous  enough  as  yet  to  prove 
that  it  is  so.  Although  often  exposure  to  cold  is  appnr- 
ently  a  cause,  in  very  man}^  cases  such  exposure  cannot 
be  traced.  It  is  a  disease,  like  bronchitis,  er3'sipelas, 
and  rheumatism,  that  strongly  predisposes  to  renewed 
attacks.  Wounds  that  can  be  regarded  as  causative 
occur  in  a  very  small  proportion  of  cases.  I  have  a 
few  times  known  an  injury  to  cause  pleurisy-  and  a  slight 


Croupous  Pneumonia.  89 

pulmonary  luemorrlinge,  which  was  followed,  in  two  or 
three  days,  1)}^  pneumonia.  The  injured  lung-tissue  was 
undouhtedh'  the  focus  of  the  pneumonic  inflammation. 

Anatomy. — Either  of  the  lungs  and  any  part  of  them 
ma}^  be  affected.  Usually  an  entire  lobe  or  lung  is 
involved.  Tiie  lower  lobe  upon  the  right  side  is  most 
frequently  the  seat  of  pneumonic  inflammation.  Not 
unfrequently  one  lobe  or  one  lung  after  the  oilier  is 
attacked,  and,  therefore,  upon  the  post-mortem  table  we 
find  different  parts  of  the  lungs  exhibiting  simultane- 
ousl}'  the  characteristic  appearance  of  two  or  more 
stages  of  pneumonic  inflammation.  Anatomically,  four 
stages  of  the  disease  are  recognizable  :  a  stage  of  (1) 
congestion,  (2)  red  hepatization,  (3)  gray  hepatization, 
and  (4)  resolution. 

In  the  stage  of  congestion  the  portion  of  the  lungs 
affected  is  enlarged,  heavier  than  natural,  but  light 
enough  to  float  on  water.  The  pleural  surface  is  red- 
dened. Upon  it  the  congested  vessels  are  often  visible 
as  red  lines.  The  lung  crepitates  and  pits  somewhat, 
when  compressed.  The  cut  surface  is  red,  and  a  pinkish 
and  often  more  bloody,  frothy  fluid  flows  from  it.  The 
alveoli  are  partly  filled  with  fluid  and  air.  Under  the 
microscope  the  epithelium  is  seen  in  places  to  be  loos- 
ened, and  some  of  the  cells  lie  in  the  alveoli,  and 
undoubtedly  •  float  in  their  fluid  contents.  Red  and 
white  corpuscles  are  also  more  or  less  numerous.  They 
are  least  numerous  at  the  beginning.  The  capillaries 
are  distended,  tortuous,  and  crowded  with  corpuscles. 

In  the  stage  of  7^ed  hepatization  the  affected  parts 
are  firm  and  hard,  still  more  enlarged,  and  two  or  three 
times  heavier  than  normal.  The  solidified  lung  sinks 
when  placed  in  watei".  'i'he  pleura  is  usually  red,  though 
it  may  be  uniformly   pale  after  death.     It  is  covered 

D3 


90  Diseases  of  the  Lungs. 

with  serum,  which  makes  it  feel  to  the  touch  as  if 
covered  with  soapj'  water,  and  usually  with  flakes  or 
patches  of  fibrin.  Tlie  lung  is  so  much  enhirged  that  it 
completely  fills  tlie  thorax,  and  its  surface  is  furrowed 
by  the  ribs.  When  removed,  it  looks  like  a  cast  of  the 
cavity.  If  compressed,  tlie  lung  does  not  crepitate.  It 
is  brittle.  The  cut  surface  is  dr3',  granular,  and  dark 
red.  The  portion  of  the  lung  immediately  adjoining 
the  solidified  part  is,  to  a  greater  or  less  extent,  oedema- 
tous.  The  opposite  lung  or  other  lobe  of  the  affected 
lung  may  appear  perfectly  normal,  or  present  evidences 
of  bronchitis.  From  the  bronchi  in  the  consolidated 
part  fibrinous  casts  can  be  drawn,  which,  w^hen  floated 
upon  water,  exhibit  the  outline  of  the  bronchioles.  The 
larger  bronchi  are  alwavs  more  or  less  inflamed. 

Under  the  microscope  the  alveolar  walls  of  the 
solidified  lung  are  seen  to  be  thickened  and  the  capil- 
laries on  them  congested.  The  air-spaces  are  compactij' 
filled  with  small  round-cells.  About  the  margins  of  the 
alveoli  desquamated,  large,  oval,  epithelial  cells  can  be 
seen,  and  here  and  there  a  few  red  corpuscles.  All 
these  cells  are  held  together  b}-  a  mesh-work  of  fibrin- 
fibres.  The  pleura  also  seems  thickened.  On  its  sur- 
face there  are  white  cells,  occasionally  red  ones,  and 
some  fibrin. 

The  stage  of  gray  hepatization  is  looked  upon  by  a 
few  pathologists  as  occurring  only  in  fatal  cases.  Often 
a  part  of  the  solidified  lung  will  be  in  this  stage  and  a 
part  in  the  former,  which  causes  the  whole  to  appear 
mottled-gray  and  red.  In  size,  weight,  and  solidity  it 
resembles  the  lesion  of  the  preceding  stage.  It  is, 
however,  more  brittle  and  easily  torn.  The  pleural  sur- 
face is  covered  more  or  less  abundantly  with  n  fibrinous 
exudate,   and   is   still  furrowed   by   the   ribs.     The  cut 


Croupous  Pneumonia.  91 

surface  is  reddish  3'ellow,  or,  later  and  more  character- 
istically, 3'ellowish  gray,  dry,  and  even  more  granular 
than  in  the  preceding  stage.  Under  the  microscope  the 
alveohir  walls  still  a[)pear  thickened  from  cellular  and 
serous  infiltration.  The  hmph-channels  are  distended 
with  granular  material  and  cells,  which  have  been 
absorbed  from  the  air-spaces.  The  capillaries  are  no 
longer  distended.  The  cells  which  fill  the  alveoli  are 
more  granular,  fattily  degenerated,  and  some  of  them 
are  disintegrated.  The  fibrin  is  in  shorter  threads,  and 
rarelv  attached  to  the  alveolar  wall.  The  contents  of 
the  alveolus  appear  more  concentrated  in  the  centre 
and  detMched  from  the  walls. 

In  the  stage  o^  resolution  the  lung  is  soft  and  flabb}'. 
The  pleura  ma}^  still  show  evidences  of  inflammation,  or 
present  a  normal  appearance.  A  pus-like  fluid  exudes 
from  the  alveoli  exposed  upon  a  cut  surlace.  Under 
the  microscope  the  air-spaces  are  seen  to  be  filled  with 
numerous  cells,  which  resemble  pus-cells,  and  an  al)un- 
dance  of  granular  matter,  which  is  cellular  debris.  The 
alveolar  walls  are  thickened  chiefly  b}-  distension  of  the 
l3'mi)h-channels,  which  are  crowded  with  absorbed  cells 
and  granular  material.  The  cells  which  in  the  earlier 
stages  of  the  disease  fill  the  alveoli  and  solidify  them 
during  resolution  disintegrate  or  migrate  into  the 
lymph-channels  and  are  absorbed.  A  pnrt  of  the  mass 
may  be  expectorated  when  it  loosens. 

The  kidneys,  liver,  and  intestinal  tract  are  usually 
congested, — at  least,  so  long  as  the  solidified  lung- 
impedes  the  circulation.  The  kidneys  and  liver  often 
undergo  albuminoid  infiltration.  After  death  the  right 
cardiac  cavities  are  usualh'  full  of  blood  and  post- 
mortem clots,  and  the  left  are  empt}'.  The  muscles  of 
the  ])od3'  are,  as  a  rule,  flabby  and  soft,  and  some  of  the 


92  Diseases  of  the  Lungs. 

fibres  may  undergo  waxy  degeneration.  Yenous  con- 
gestion of  the  bniin  is  usual. 

Rarel}'  a  case  of  croupous  pneumonia  is  met  with  in 
whicli  the  lesion  becomes  chronic.  Instead  of  resolu- 
tion taking  place  and  the  fibrinous  clot  originall}'  filling 
the  alveoli  undergoing  solution  and  absorption,  it 
becomes  organized.  The  round-cells  which  fill  it  are 
gradually  transformed  into  connective-tissue  cells.  The 
air-spaces  are  thus  permanentl3'  obliterated.  As  the 
connective  tissue  is  developed  contraction  occurs,  and 
tlie  solidified  lung  grows  smaller  and  hard.  Often 
bronchiectatic  cavities  are  formed  in  tliese  cases. 
Tuberculosis,  abscess,  and  gangrene  are  other  lesions 
that  develop  occasionally  in  pneumonically-inflamed 
tissues. 

Symptoms. — Different  cases  of  croupous  pneumonia 
vary  in  the  development  and  duration  of  their  symp- 
toms. A  majority,  however,  follow  a  typical  course. 
In  the  typical  cases  there  are  rarely  prodromal  symp- 
toms. Malaise  may  be  felt  for  one  or  two  days  preced- 
ing the  attack.  It  is  usually  ushered  in  by  a  severe 
chill  of  considerable  duration.  Almost  at  once  the 
sufferer  feels  that  he  is  very  ill.  During  the  da}'  follow- 
ing the  chill,  and  the  two  or  three  next,  the  patient 
develops  characteristic  symptoms.  The  face  locdis  full 
and  flushed.  Tlie  skin  is  dr}'  and  hot.  The  pulse  is 
(piick,  full,  and  firm.  The  tem[)erature  commonh'  is 
from  103°  to  104°  F.  Soon  after  the  Initial  chill  pain 
is  felt,  in  the  region  of  the  ni[)ple.  upon  the  affected 
side.  It  is  aggravated  greatly  by  coughing  or  deep 
breathing.  Alrliougii  coughing  occurs,  it  is  suppressed 
as  much  as  possible,  because  of  the  pain.  The  respira- 
tions are  from  30  to  40  per  minute.  They  are  short  or 
superficial.     The    patient    lies     upon    his    back    or    the 


Croupous  Pneumonia.  93 

affected  side.  His  tongue  is  covered,  at  first,  by  a 
white  coat,  whicli  soon  becomes  brownish  and  dry. 
Appetite  is  wanting.  Thirst  is  considerable.  The 
bowels  are  constipated.  Delirium  often  exists.  He  is 
usually  extremely  ill.  In  favorable  cases,  at  the  end  of 
the  fifth  or  seventh  da3^,  or,  exceptionally,  by  the  ninth 
or  thirteenth  da^^,  the  fever  suddenly  disappears. 
Simultaneously  the  other  distressing  symptoms  lessen 
or  disappear.  The  breathing  becomes  much  less  rapid. 
The  pulse  becomes  almost  or  quite  normal.  The  mind 
is  clear.  The  skin  is  cool.  A  copious  sweat  often 
accompanies  the  subsidence  of  the  fever.  Coughing 
persists.  Sometimes  the  side  is  still  painful,  but  usuall}^ 
it  is  not.  The  appetite  improves.  Digestion  seems 
more  perfect,  and  thirst  is  no  longer  felt. 

In  unfavorable  cases,  on  the  fifth  or  sixth  day  the 
delirium  becomes  duller.  A  semi-comatose  or  somno- 
lent condition  develops.  The  pulse  grows  soft,  smaller, 
and  quicker.  By  degrees  the  skin  grows  cool  and 
ashen  in  color,  and  is  covered  with  a  clammy  sweat. 
These  changes  are  first  noticed  in  the  extremities.  In- 
voluntary discharges  from  the  bowels  and  bladder  are 
usual.  The  respiratory  movements  become  more  and 
more  shallow  and  labored.  The  nares  dilate,  and  the 
larynx  is  lifted  with  each  inspiration.  Death  oftenest 
occurs  on  the  sixth,  eighth,  or  ninth  day.  Its  immediate 
cause  is  usually  either  heart-failure  or  suffocation  from 
cedema  of  the  lungs. 

In  the  course  of  the  disease  the  physical  signs — first 
of  congestion,  and  later  of  consolidation,  of  the  lungs 
— develop.  Usually  the  earliest  signs  of  a  lung-lesion 
are  detected  on  the  second  day  of  the  illness,  but  their 
appearance  may  be  delayed  to  the  third  or  fourth  day. 

In  a  considerable  number  of  cases  the  fever  docs 


94  Diseases  of  the  Lungs. 

not  leave  suddenly,  but  gradually  subsides  by  h'sis.  In 
secoudaiy  pneumonias  there  is  usually  no  chill  at  the 
inception  of  the  attack,  and  all  the  S3'mptoms  are 
obscured  hy  those  of  the  primary  disease.  The  exist- 
ence of  pneumonia  is  suspected  only  from  the  unusual 
rapidity  of  respiration,  and  proved  b}^  ph^'sical 
examination. 

The  sideache,  which  is  an  early  and  in  man}^  cases 
a  bothersome  sym[)tom,  is  not  always  present.  In  cases 
of  secondary  pneumonia  it  is  generally  wanting.  The 
pain  varies  much  in  degree.  It  is  usually  stitch-like 
and  dull  simultaneously.  It  is  aggravated  by  deep 
breathing  and  coughing.  Often  there  is  some  tender- 
ness to  the  touch.  The  pain  is  usualh'  felt  about  the 
nipple,  or  a  little  outside  of  it,  on  the  affected  side. 
The  pain  is  the  result,  chiefl}',  if  not  wholl3',of  pleuris3^ 
That  a  neuralgia  ma}'  accompany  the  pleuritic  pain  is 
possible,  for  in  rare  cases  pain  is  not  felt  upon  the  side 
on  which  the  lung  is  inflamed,  but  upon  the  opposite 
side. 

Coughing  is  an  earl}^  and  almost  constant  symptom. 
In  primar}'  pneumonia  it  is  usuoll}-  severe.  It  is  sup- 
pressed, as  far  as  it  can  be,  because  of  the  pain  which  it 
excites.  In  secondary  pneumonia,  and  especially  wlien 
the  primary  disease  causes  mentnl  stui)or, — such  as  ex- 
ists in  typhoid  fever,  for  instnnce, — the  cough  may  be 
absent.  An  ex})ectorate  may  be  wanting  in  children 
and  aged  persons  :  in  the  one  been  use  tliey  do  not  know 
how  to  expectorate,  and  in  the  other  because  they  are 
too  feeble.  In  others  weakness  or  the  failure  to  cough 
occasionally  prevents  expectoration  ;  as  a  rule,  it  is 
present.  At  first  the  sputa  is  scnnt  and  adhesive.  It  is 
often  expelled  from  the  mouth  with  difficulty.  As  soon 
as  the  blood   and  fibrinous  exudate  has  formed  in  the 


Croupous  Pneumonia.  95 

lung  the  sputa  becomes  red  ;  it  is  a  dull,  brick  red.  The 
color  is  produced  by  red  blood-corpuscles  in  it,  but  also, 
and  chiefljs  bv  blood-coloring  matter  in  solution.  In  a 
small  proportion  of  cases  tlie  sputa  is  purplish  red  and 
likened  to  "  prune-juice."  In  a  considerable  number  of 
cases  the  sputa  is  not  raised  from  the  lungs,  but  from 
the  larger  bronchi,  and  is  not  red.  In  most  instances  in 
which  the  sputa  is  abundant  there  can  be  found  in  it 
small  gra}^  or  yellowish-gra\^  balls,  which,  if  dropped 
upon  water  and  shaken,  will  unfold  and  reveal  them- 
selves as  branching  fibrinous  casts  of  the  smaller  bron- 
chi. Rarely,  these  are  composed  of  the  spiral  threads 
which  so  uniformly  form  bronchial  casts  in  asthma. 
The  sputa  contains  mucus-corpuscles,  some  cells  that 
resemble  those  of  pus,  red  blood-cells,  and  a  few  epi- 
thelial cells.  Micro-organisms  of  various  kinds  can  be 
found,  especiall}'  the  cocci  sui)posed  to  be  peculiar  to 
pneumonia.  Graduallj^  the  sputa  loses  its  red  color, 
becomes  purulent  and  loose,  then  frothj',  and  finally  it 
ceases. 

Respiration  is  always  abnormally  quick.  It  is  shal- 
low, especiall^^  upon  the  affected  side.  The  rate  of 
respiration  is  abnormal,  in  that  it  does  not  correspond 
to  the  pulse-rate  or  temperature.  In  health  and  in  other 
fevers  the  pulse  bears  about  the  ratio  to  the  respiration 
of  4 J  to  1,  but  in  pneumonia  it  is  nearl}^  2  to  1.  The 
number  of  respirations  is  commonly  45  per  minute,  and 
may  be  60  or  more.  This  peculiarit}''  of  the  respiration- 
pulse  ratio  is  almost  pathognomonic.  The  rapidity  of 
breathing  is,  in  part,  due  to  the  pleuris}^,  which  prevents 
deep  respiration  because  of  the  pain.  It  is  also  quick, 
because  of  the  increased  temperature  of  the  blood. 
Something  else  must  also  excite  the  respiration,  for  it  is 
quick,  out  of  proportion  to  the  temperature,  even  when 


96  Diseases  of  the  Lungs. 

pleuritic  pains  are  not  felt.  The  diminution  of  lung- 
space  does  not  account  for  the  quickened  breathing; 
for,  after  crisis,  when  the  temperature  has  fallen  and  the 
pain  has  ceased,  the  respirator}'  movements,  though 
quicker  than  normal,  are  one-half  or  two-thirds  less  than 
earlier  in  the  illness.  It  is  probable  that  respiration  is 
quickened,  at  least  parti}',  by  a  poison  wiiich  acts  upon 
the  nervous  S3'stem,  and  is  produced  in  the  course  of 
pneumonic  inflammation. 

The  pulse  bears  about  the  usual  ratio  to  the  increase 
of  temperature.  It  is  quick,  usually  from  100  to  120, 
and  at  first  full  and  strong.  In  favorable  cases  it 
remains  full  and  strong ;  in  unfavorable  cases  it  grows 
soft  and  small  and  quicker.  An  intermittent  pulse  is  an 
unfavorable  S3'mptom,  and  is  due  to  a  complication  or 
feebleness  of  the  heart.  An  abnormally  slow  pulse 
usuall}'  indicates  disease  of  the  brain. 

The  temperature  varies  in  its  range  and  course.  It 
is  rarely  more  than  105  degrees  or  less  than  102  degrees. 
In  typical  cases  it  pursues  a  continuous  course  until 
crisis  occurs,  on  the  fifth  to  the  niuth  day.  At  the  onset 
of  the  disease  the  temi)erature  rises  rapidly,  and  in 
twelve  hours  is  usually  103  degrees.  Its  highest  point 
is  generall}'  reached  on  the  third  da}- ;  on  the  fifth, 
seventh,  or  ninth  the  temperature  falls  to  normal.  Be- 
fore the  crisis  the  dail}'  range  is  about  1  degree.  In 
most  instances  the  temperature  falls  during  the  night 
of  the  fifth  da}',  and  thereafter  remains  normal.  Crisis 
is  sometimes  less  abrupt  :  for  instance,  during  the  fifth 
night  the  temperature  will  fall  from  104.5°  to  102°  F.  ; 
during  the  sixth  d:i\  it  will  rise  to  102.5°  F.,and  during 
that  night  fall  to  normal  and  remain  there.  False  crises 
may  also  occur ;  most  frequently  they  hap[)en  upon  the 
third   day.      The  temperature   may  fall  to  normal,  but 


Cr^oupous  Pneumonia.  9*1 

usual!}'  only  to  100°  F.  or  thereabouts.  If  such  a  crisis 
occur  earlier  than  the  fifth  day  it  is  rarely  permanent. 
The  typical  or  classical  cases  of  pneumonia  convalesce 
with  a  crisis,  but  a  considerable  proportion  of  cases 
convalesce,  after  a  slow  subsidence  of  temperature,  by 
l3'Sis.  The  whole  temperature-curve  then  closely  resem- 
bles that  of  t^'phoid  fever,  but  its  course  is  usuall}' 
shorter. 

During  the  height  of  the  disease  the  urine  is  scant  in 
quantit}^,  red,  and  often  cloudy.  Its  specific  gravity  is 
increased.  The  relative  proportion  of  urea  that  it  con- 
tains is  greater  than  natural.  Sodium  chloride  is  almost 
or  quite  wanting.  Occasionally,  small  amounts  of  albu- 
men can  be  found  in  it.  If  nephritis  does  not  follow  or 
complicate  the  pneumonia  the  albuminuria  ceases  when 
the  fever  subsides. 

The  signs  elicited  by  a  physical  examination  are  all 
important  for  diagnostic  purposes.  In  the  stage  of 
congestion  the  respiratory  movements  appear  to  be  defi- 
cient upon  the  affected  side.  This  is  partly  due  to  the 
congestion  and  obstruction  of  air-cells,  and  partly  to  the 
pain  which  full  expansion  would  cause.  Vocal  fremitus 
over  the  affected  parts  is  normal  or  increased.  Reso- 
nance is  normal,  or  sometimes,  just  before  consolidation 
occurs,  semi-tympanitic.  Auscultation  reveals  the  most 
characteristic  sign, — fine  crepitant  rales. 

In  tiie  stages  of  consolidation  the  chest  over  the 
affected  area  usuall}^  seems  slightly  distended,  and  is 
almost  motionless.  Yocal  fremitus  is  alwaj^s  increased. 
There  is  dullness  over  the  consolidated  parts  ;  it  is  ex- 
tensive, usually  covering  an  entire  lobe,  or  a  large  part 
of  one.  The  area  of  dullness  is  frequently  bordered  b}' 
a  narrow  area  that  is  semi-tj'mpanitic  ;  over  the  remain- 
der  of  the   lung  the   resonance  may  be  normal.     The 

5    E 


98  Diseases  of  the  Lungs. 

respiratory  sounds  are  bronchial  whenever  there  is  con- 
solidation. An  abnormal  degree  of  resistance  is  often 
felt  by  the  hand,  when  i)ressed  upon  tlie  side,  or  Mhen 
percussion  is  being  practiced. 

As  resolution  progresses  duHness  gradually  lessens, 
or  is  replaced  temporaril}^  by  semi-t^'mpanitic  percus- 
sion-sounds, which  are  due  to  the  relaxed  condition  of 
the  lung-tissue.  Fremitus  graduall}^  becomes  normal. 
Coarse,  moist  rales  are  usuall}-  present.  If  there  is 
much  bronchitis  similar  rales  may  be  heard  in  the  stage 
of  consolidation.  The  distension  of  the  side  ceases  and 
the  respirator}'  movements  become  more  normal. 

As  different  portions  of  the  lungs  may  be  successively 
involved,  we  ma}'  be  able  to  demonstrate  resolution  in 
one  part  and  consolidation  in  another.  Pleurisy,  with 
eflusion,  complicates  a  few  cases.  Pericarditis  and 
endocarditis  are  rarer  complications.  Meningitis  is  an 
occasional,  and  usually  a  fatal,  complication. 

Often  dual  names,  such  as  typho-pneumonia,  are  ap- 
plied to  individual  cases  descriptive  of  complications. 
The  following  can  be  recognized  as  more  distinct  vari- 
eties :  Protracted  pneumonia  is  the  form  in  which  the 
fever  disappears  b}"  13'sis.  Spreading  pneumonia  is  the 
form  in  which  the  lesion  graduall}'  increases  b}^  involv- 
ing neighboring  tissue  in  successive  invasions.  Wan- 
dering pneumonia  is  the  form  in  which  different,  but  not 
contiguous,  parts  of  the  lungs  are  involved  successivel}". 
Relapsing  pneumonia  is  the  form  in  which,  after  crisis 
has  occurred  and  convalescence  has  apparent!}'  been 
established,  the  lung  again  becomes  consolidated,  either 
where  it  first  was  or  at  some  other  point.  Intermittent 
pneumonia  is  a  name  applied  to  rare  cases  which  are 
probably  complicated  by  malaria ;  all  the  symptoms  of 
the  stage  of  congestion  will  suddenly  develop,  persist 


Croupous  Pneumonia.  99 

for  three  or  four  hours,  and  then  disappear,  leaving  the 
patient  apparently  well.  The  next  daj^,  or  the  second 
day,  a  similar  attack  will  occur.  Several  of  these  threat- 
eiiings  of  pneumonia  ma}^  occur,  each  a  little  more 
intense  than  the  preceding  one,  and  at  last  a  full  devel- 
opment of  the  disease  will  take  place.  When  established, 
such  a  case  may  follow  the  classical  \>y\>Q  of  the  disease. 

So-called  chronic  23?i(?i<mo?im  follows  the  acute 
attacks.  Sometimes  fever  persists  for  weeks,  and  even 
months,  but  it  is  hectic  in  t^pe.  Often,  in  such  cases, 
an  abscess  forms,  or  tubercular  complications  develop. 
In  other  cases  the  fever  ceases,  and  a  part  of  the 
patient's  sti'ength  slowly  returns  ;  but  he  remains  short- 
winded,  often  coughs  slightl}'',  and  fills  the  affected  side 
less  than  the  opposite.  The  affected  side  is  a  little  dull, 
and  increased  fremitus  persists  there.  The  respiratory 
sounds  may  be  consonant,  but  more  frequently  they  are 
low  and  broncho-vesicular.  The  thorax  on  that  side 
slowly  contracts.  The  opposite  lung  becomes  emphy- 
sematous, is  h3'perresonant,  and  the  respiratory  sounds 
in  it  are  exaggerated.  Resolution  may  finally  take 
place,  but  often  the  lung  is  permanently  crippled. 

Diagnosis. — In  most  cases  a  direct  diagnosis  can  be 
made  from  the  sudden  onset  of  the  characteristic  symp- 
toms ;  from  the  course  of  the  fever  ;  from  the  occur- 
rence of  rusty  sputa;  from  the  characteristic  pulse- 
respiration  ratio  ;  and  from  ph3'sical  signs. 

It  can  be  distinguished  from  drj'  pleurisy  by  the 
greater  severity  of  the  disease,  by  the  pulse-respiration 
ratio,  b}"  the  rusty  sputa,  and  the  physical  signs  of 
lung  congestion  or  consolidation.  It  can  be  distin- 
guished from  typhoid  fever  by  the  absence  of  abdom- 
inal S3'mptoms  and  of  the  t3^phoid  rash  ;  b3'  the  presence 
of  the  usual  pulse-respiration  ratio ;  often  of  a  bloody 


100  Diseases  of  the  Lungs. 

sputa,  find  the  ph3'sicfil  signs  of  lung  consolidation.  It 
is  more  difficult  to  distinguish  between  h^^postatic  con- 
gestion and  the  catarrhal  consolidation  which  frequently 
accompanies  it,  and  a  complicating  croupous  pneumonia. 
If  fibrinous  casts  are  found  in  the  sputa  they  are  quite 
characteristic  of  croupous  pneumonia.  The  congestion 
is  usually  bilateral,  and  involves  the  dependent  parts  of 
both  lobes  of  the  lungs,  while  croupous  pneumonia  is 
usually  unilateral,  and  involves  only  one  lobe, — gener- 
ally- the  lower.  Hj^postatic  congestion  does  not  cause 
as  great  ph3-sical  prostration  as  does  a  complicating 
pneumonia. 

Treatment. — There  is  no  sj^ecific  treatment  for 
croupous  pneumonia.  It  must  be  treated  sj-mptomati- 
cally.  The  mildest  cases  require  good  nursing,  and 
almost  no  medication.  The  severe  cases  require  a  sup- 
porting and  stimulating  treatment.  The  disease  is  espe- 
cially characterized  b}-  great  prostration,  which,  in  some 
cases,  might  almost  be  called  shock.  For  its  relief,  as 
well  as  to  allay  the  pleuritic  pains  which  are  usually  at 
first  felt,  opiates  must  be  employed.  When  pneumonia 
is  of  moderate  severit}-,  and  occurs  in  one  who  is  robust, 
Dover's  powder  is  a  useful  preparation.  If,  however, 
the  patient  is  debilitated  at  the  start,  the  opiate  should 
be  combined  with  quinine.  A  pill  of  morphia  and  sul- 
phate of  quinine  is  then  the  "most  conveniently  admin- 
istered. The  opiates  should  be  used  in  such  doses  and 
repeated  with  such  frequenc\'  as  to  insure  at  least 
moderate  relief  from  pain,  but.  if  possible,  constant 
drowsiness  should  not  be  caused.  When  quinine  is 
used,  from  10  to  12  grains  dailj''  is  sufficient. 

In  the  stage  of  congestion  depleting  agents  rarely 
will  shorten  the  course  of  the  disease,  or  even  prevent 
consolidation.     Venesection  has  most  frequently  accom- 


Cr^oiipous  Pneumonia.  101 

plished  this.  It  can  be  safely  practiced  upon  sthenic 
cases,  but  is  almost  invariablj^  useless  for  those  who  are 
not  vigorous  and  robust  when  attacked  by  the  disease. 
Instead  of  venesection,  especially  in  asthenic  cases, 
blisters,  diy^  cups,  and  fomentations  on  the  affected  side 
are  indicated.  Aconite  and  veratrum  have  been  com- 
mended in  this  stage,  because,  b}'  relaxing  the  peripheral 
vessels,  a  depletion  is  produced.  They  must  be  used 
with  caution,  however,  and  onl}'  in  the  stage  of  conges- 
tion, for  they  tend  to  weaken  the  heart's  action.  There 
is  so  much  danger  to  life  in  this  disease,  because  of  car- 
diac w^enkness,  that  its  strength  must  always  be  pre- 
served. After  consolidation  has  taken  place,  the 
ammonium  carbonate  (grm.  0.18  to  0.3 — gr.  iij  to  v) 
or  mild  chloride  of  mercury  (grm.  0.015  to  0.06 — gr.  ^ 
to  j)  may  be  given  to  hasten  the  solution  of  the  exudate. 
The  severest  cases  must  be  treated  like  the  milder 
ones,  but  there  are  two  great  dangers  to  life  which  must 
be  guarded  against.  The  first  is  heart-failure,  and  the 
second  is  suffocation.  In  order  to  maintain  the  heart's 
vigor,  resort  must  be  had  to  cardiac  tonics  and  diffusible 
stimulants.  The  best  of  the  latter  group  of  remedies  is 
ammonium  carbonate.  In  order  to  get  its  full  effects  as 
a  cardiac  stimulant,  it  must  be  taken  in  solution,  for  its 
irritation  of  the  gustatory  nerves  reflexl}-  excites  the 
heart  to  more  vehement  action.  After  absorption  it 
also  stimulates  it.  The  effect  of  ammonia  is  very 
transitory.  It  must,  therefore,  be  often  repeated.  The 
doses  may  be  from  grm.  0.18  to  0.3  (gr.  iij  to  v)  everj' 
hour.  A  solution  1  part  of  camphor  in  10  of  olive-oil 
has  been  used,  with  excellent  eflect,  hy  hypodermatic 
administration.  Diffusible  stimulants  are  chiefl}^  indi- 
cated when  failure  is  imminent.  When  the  impulse  of 
the  heart  first  loses  its  force  fulness  and  the  pulse  begins 


102  Diseases  of  the  Lungs. 

to  soften  or  to  grow  small,  cardiac  tonics,  such  as  digi- 
talis and  strophantlius,  are  indicated.  The  latter  is  to 
be  preferred,  for  it  provokes  qnite  as  forceful  contrac- 
tion of  the  heart  as  digitalis,  and  does  not  contract  the 
peripheral  vessels  to  the  same  extent.  The  latter  effect 
should  be  avoided,  because  it  increases  the  work  of  the 
heart.  The  tinctures  of  strophantlius  and  digitalis  are 
the  most  certain  preparations  for  administration.  I  have 
found  10  minims  of  each,  repeated  ever\'  four  or  three 
hours,  the  best  dose  for  steady  use,  although,  at  times, 
a  little  larger  or  a  little  smaller  dose  ma}'  be  preferable. 
In  many  severe  cases  it  is  necessary  to  give  those  reme- 
dies almost  from  the  beginning  of  the  disease. 

Spongings  of  the  bod}',  showers,  and  douches,  espe- 
cially when  a[)plied  about  the  chest  and  the  back  of  the 
neck,  are  strong  cardiac  and  respiratory  stimulants. 
They  also  are  chiefly  indicated  when  heart-failure  is 
imminent. 

While  these  especial  cardiac  stimulants  and  tonics 
are  useful  as  prods  or  goads  to  the  flagging  organ,  it 
must  not  be  forgotten  that  the  strength  which  they 
excite  is  a  temporary  one.  They  call  forth,  as  it  were, 
the  organ's  reserve  strength.  To  give  true  strength  to 
the  heart  reliance  must  be  placed  upon  food.  Strj'chnia 
and  quinine  are  often  serviceable,  because  the}"  prompt  a 
more  rapid  and  better  degree  of  general  nutrition.  They 
can  be  advantageously  administered  in  combination  with 
the  cardiac  tonics. 

Suffocation  generally  results  from  pulmonar\'  oedema. 
I  need  not  repeat  the  treatment  which  is  indicated  when 
it  occurs.  (See  page  81.)  If  pulmonary  oedema  exist 
digitalis  is  to  be  preferred  to  strophantlius,  because  it 
does  contract  the  vessels,  and  ma}^  possibly  hinder 
exudation    through    their    walls.     Atropia,    ergot,   and 


Croupous  Pneumonia.  103 

str3"chnia  are  the  other  drugs  upon  Avhich  reliance  must 
be  placed.  The  inlialation  of  oxygen  will  save  a  number 
of  otherwise  fatal  cases. 

When  bronchitis  is  severe  or  precedes  pneumonia  it 
greatly  increases  the  danger  to  life,  as  it  increases  the 
tendenc}^  to  pulmonary  oedema.  Opiates  must  be  used 
with  caution  in  these  cases,  for,  by  suppressing  cough, 
they  prevent  the  clearing  of  the  air-tubes,  and  they  also 
tend  to  dilate  the  peripheral  vessels,  which  may  hasten 
oedema. 

Antipyretics,  especially  antipyrin  and  its  congeners, 
have  been  extensivel}^  used  in  pneumonia,  but  with 
doubtful  efflcac3\  The  temperature  is  rarel}^  so  high 
that,  in  itself,  it  is  a  source  of  danger;  therefore,  it  is 
not  necessary  to  lower  it  in  order  to  save  life.  Anti- 
pja'in,  acetanilid,  and  similar  drugs  depress  the  nervous 
sj'stem,  frequently  increase  the  depression  or  condition 
of  shock  which  the  disease  produces,  and  may  even  pro- 
duce a  state  of  collapse.  The}^  lessen  the  oxygen- 
carrying  power  of  the  blood.  In  many  cases  it  is  \e\'y 
important  to  preserve  this  power.  To  depress  the 
temperature  does  not  shorten  the  course  of  the  fever  or 
modify  the  important  local  lesions.  The  statistics  of 
cases  treated  with  antipyretics  show  often  an  increased 
mortality,  and  certainly  not  a  greater  ratio  of  lives 
saved.     I  have  discontinued  their  use  in  these  cases. 

Quinine  is  especially  indicated  in  atonic  cases,  and 
then  is  best  given  in  daily  doses  of  10  or  12  grains. 
When  malarial  trouV)les  complicate  the  pneumonia  larger 
doses  may  be  required. 

Alcoholics  have  been  used  in  pneumonia  with  great 
freedom.  The}^  have  been  prescribed  for  two  purposes, 
neither  of  which,  I  believe,  is  attained  by  them.  They 
have  been  used  as  foods  and  as  diffusible   stimulants. 


104  Diseases  of  the  Lungs. 

Whether  thej'  are  foods  or  not  is  a  question  still  debated. 
It  is  proven,  however,  that  those  who  take  them  cannot 
accomplish  as  much  work  or  endure  as  much  hardship 
as  those  wlio  do  not.  They  are  not,  therefore,  strength- 
giving.  As  diffusible  stimulants,  therapeutists  state 
that  they  provoke  stronger  pulsations  of  the  heart  when 
given  in  small  amounts.  If  their  anaesthetic  effects  are 
produced  they  weaken  the  heart's  action.  Even  in  small 
doses  no  stimulation  is  produced  in  persons  who  are 
accustomed  to  them.  Such  effects  are  very  transitorj' ; 
and,  if  the  drug  is  frequently  repeated  in  order  to  main- 
tain them,  its  ansesthetic  properties  are  manifest.  In 
large  amounts, — several  ounces  daily, — as  it  is  often 
prescribed,  it  lessens  the  oxj^gen-carr^-ing  powers  of  tlie 
blood,  and  thus  delays  tissue  change.  The  drug  is  not 
necessary  for  the  treatment  of  this  disease,  as  abundant 
clinical  evidence  has  demonstrated  to  me.  In  Mercy 
Hospital,  during  the  last  ten  years  the  death-rate  from 
pneumonia  has  been  a  little  less  than  12  per  cent.,  though 
no  alcohol  was  employed  in  the  treatment  of  the  cases. 
During  the  same  time  the  death-rate  in  other  Chicago 
hosi)itals.  where  alcohol  was  used  with  greater  or  less 
freedom,  was  28  to  38  per  cent.  I  have  no  hesitation  in 
discarding  alcohol  in  the  treatment  of  pneumonia.  I 
believe  that  often  it  has  done  harm. 

Pneumonia  commonh^  runs  a  short  but  severe 
course.  Ver}-  great  prostration  ma}'  be  felt  when  con- 
valescence is  first  established,  but  usually  strength  is 
rapidh'  recovered.  However,  those  who  were  feeble 
when  attacked  by  the  malady  may  recover  slowl3\  It  is 
important  in  all  cases,  but  especially  in  the  latter  group, 
to  maintain  strength  during  the  illness.  As  an  inclina- 
tion for  food  is  usually  wanting,  it  must  be  taken  as  a 
necessity.     It  should  be  given  in  a  form  as  concentrated 


Croupous  Pneumonia.  105 

and  as  easily  digested  as  possible.  Milk  is  most  uni- 
forml}^  the  best  diet.  A  little  should  be  administered 
every  hour  or  two  during  the  severest  portion  of  the 
illness.  It  will  be  least  liable  to  disturb  the  stomach  or 
cause  repugnance  if  it  is  thus  administered.  If  the 
heart  is  weak,  beef-tea,  or  chicken-broth,  or  strong 
coffee  should  also  be  given.  They  are  stimulants  rather 
than  foods.  During  convalescence  food  should  be 
simple  in  character,  but  should  be  gradual  13- varied' as 
the  appetite  returns. 

In  chronic  pneumonia  we  must  combat  a  tendenc}' 
to  abscess  formation,  or  treat  abscesses,  if  the}''  exist. 
To  check  the  iuflammatiou,  blisters  or  sometimes 
milder  counter-irritants,  occasionally  applied,  are  useful. 
Anodynes  are  needed  to  allay  cough,  when  it  persists. 
Strength  must  be  conserved  and,  if  possible,  improved 
by  careful  feeding.  If  the  fever  disappear,  the  ten- 
denc}'  of  the  affected  side  to  contract  and  to  prevent  the 
full  inflation  of  the  lung  must  be  counteracted  by 
respirator}^  gymnastics.  At  first,  gentle,  enforced,  deep 
breathing,  and,  later,  the  pneumatic  cabinet,  or,  better 
still,  a  residence  for  a  few  months  in  high  altitudes, 
should  be  tried.  The  respiratory  g^-mnastics  expand 
the  lungs,  help  to  lessen  tlieir  congestion,  and  prevent 
permanent  contraction  of  the  affected  side.  The  dry 
air  of  high  altitudes  also  promotes  a  more  rapid  absorp- 
tion of  inflammatory  exudates.  If  an  irregular  remit- 
ting fever  persist,  which,  although  not  enough  to  keep 
the  patient  bedridden,  is  enough  to  make  high  altitudes 
dangerous,  a  residence  at  low  altitudes,  in  dry  climates, 
— such  as  can  be  found  in  Western  Texas,  Arizona,  and 
Southern  California, — is  exceedingly  beneficial.  XJsuall}' 
such  a  change  improves  the  appetite,  tempts  to  more 
active  exercise,  to  the  rapid  absorption  of  the  exudate, 

5* 


106  Diseases  of  the  Lungs. 

and,  with  these  changes,  to  the  disappearance  of  tem- 
perature. If  abscesses  or  tubercular  disease  super- 
vene, they  must  be  treated  as  they  would  be  under 
other  circumstances.  The  medical  treatment  of  the 
chronic  cases  must  be  symptomatic  and  tonic.  Iron 
and  bitter  tonics  must  usually  be  given. 

Pneumonia  is  ver}^  frequently'  a  fatal  disease.  The 
proportion  of  fatal  cases  has  been  variously  estimated 
in  different  hospitals  and  by  different  observers.  It 
varies  also  from  year  to  3'ear.  The  mortality  is  esti- 
mated as  high  as  25  per  cent.,  in  some  hospitals.  In 
my  own  hospital  and  private  practice  during  the  last 
five  years,  it  has  varied  from  4  to  12  per  cent.  It  is 
especially  fatal  in  persons  more  than  40  3-ears  of  age. 
In  children  and  in  the  earlier  years  of  manhood  recovery 
occurs  in  a  very  large  proportion  of  cases.  In  those 
who  are  addicted  to  the  free  use  of  alcoholics  the  mor- 
talit}'  is  mucli  greater  than  in  total  abstainers.  Croup- 
ous pneumonia  of  the  lung's  apex  is  especialh'  dangerous, 
for  it  is  usual!}'  accompanied  and  followed  by  tubercu- 
losis, if  it  does  not  at  once  cause  deatli.  Complications 
alwaj's  greatl\'  increase  the  danger  to  life.  A  tempera- 
ture of  more  than  105  degrees  must  usually  be  regarded 
as  significant  of  danger.  A  temperature  of  104  degrees 
accompanies  tlie  disease  in  its  moderateh'  severe  form. 
It  is  found,  also,  that  an  increase  of  temperature  after 
the  fourth  day  is  usually  significant  of  an  unfavorable 
result. 


CHAPTER  XL 
Cirrhosis  of  the  Lung. 

Anatomy. — Cirrhosis  of  the  lung  is  often  called  in- 
terstitial pneumonia.  It  results  from  the  formation  of 
large  amounts  of  new  connective  tissue,  which  begins 
with  infiltration  of  the  interstitial  tissue  of  the  lungs 
by  embryonic  connective-tissue  cells.  The  change  may 
involve  the  whole  of  the  lungs,  and  is  then  verj'  mod- 
erate in  degree.  It  may  be  very  circumscribed,  or 
limited  to  a  single  lobe,  or  more  frequently  to  a  part  of 
a  lobe.  When  the  lesion  is  extensive  it  causes  contrac- 
tion of  the  lung,  so  that,  for  instance,  an  upper  lobe 
may  be  transformed  into  a  small  mass  of  firm,  tough, 
unaerated  tissue  not  one-quarter  its  normal  bulk.  More 
frequentl}^  smaller  areas  are  involved,  which  produce  de- 
formities of  the  lungs  and  render  portions  of  them  use- 
less for  respirator}'  purposes.  If  the  cirrhotic  tissue  is 
cut  into,  it  often  creaks  like  cartilage.  Usuall}'  the 
pleural  cavity  over  cirrhotic  masses  is  obliterated  by 
adhesions.  If  a  section  is  made  into  a  lung  containing 
a  cirrliotic  area,  the  diseased  portion  appears  as  a  band, 
or  more  or  less  extensive  area  of  gra}',  compact,  hard, 
and  fibrous  tissue.  About  it  the  air-spaces  nre  irregu- 
larlj'  shaped  and  have  thick  walls,  which  deform  them. 
As  the  cirrhotic  mass  enlarges  the  interstitial  tissue 
becomes  thicker  and  thicker,  and  the  air-space  is  dimin- 
ished proportionately  and  finally  is  obliterated.  Pig- 
ment is  often  deposited,  in  considerable  amounts,  in  the 
cirrhotic  tissue,  and  produces  a  mottling  of  the  cut  sur- 
face. Bronchial  tubes  in  this  tissue  are  often  dilated 
(see  page  57).      Less  frequently"  they  are  obstructed  or 

(107) 


108  Diseases  of  the  Lungs. 

obliterated  hy  the  contmcting  scar-tissne.  Adhesive 
pleuritis  and  contracting  cirrhotic  lung-tissue  often  pro- 
duce a  deformity  of  the  thorax,  and  impede  breathing 
by  drawing  togotlier  the  ribs,  narrowing  and  making  im- 
mobile the  intercostal  spaces.  Adhesions,  the  results  of 
cirrhotic  changes  in  the  lungs,  often  occur  between  the 
lungs  and  pericardium,  and  result  in  displacement  of 
tiie  heart.  Whenever  the  cirrhotic  change  is  exten- 
sive, hypertrophy  of  the  right  ventricle  occurs  in  order 
to  compensate  for  the  obstruction  to  tiie  pulmonary  cir- 
culation offered  by  the  obliteration  of  many  capillaries 
and  small  arteries 

Symptoms. — The  lesion  is  always  secondary-,  and 
the  onh'  appreciable  signs-  of  diagnostic  value  tiiat  it 
produces  are  physical  ones.  Small  or  deeply-seated 
jireas  of  cirrhosis  mav  exist  and  may  not  be  de- 
monstrable before  death.  Larger  areas,  and  especially 
superficial  cirrhosis,  cause  retraction  of  a  portion  of 
the  thoracic  wall,  which  is  visible  to  even  a  carelessly- 
observing  eye.  This  retraction  occurs  most  frequently 
about  the  apices,  as  it  causes  the  flattening  of  the  chest 
in  consumption.  It  less  frequently  produces  deformi- 
ties about  the  lower  part  of  the  thorax.  The  chest  is 
alwaj's  diminished  in  size  by  these  changes,  as  well  as 
rendered  irregular  in  shape.  The  ribs  are  drawn  to- 
gether and  comparatively  immovable,  so  that  respiration 
is  not  equal  upon  both  sides  of  the  thorax,  and  is 
especially  limited  at  the  points  of  retraction.  The  other 
physical  signs  are  those  of  consolidation  of  lung-tissue. 
Yocal  fremitus  over  the  area  of  consolidation  is  in- 
creased, and  often  bronchial  fremitus  can  be  detected. 
Dullness  is  noticeable  at  the  same  point.  It  is  usually- 
relative.  Its  com])leteness  depends  upon  the  size  and 
superficial     position    of    the    solid,    cirrhotic     tissue. 


Cirrhosis  of  the  Lung.  109 

Broncho-vesicular  or  bronchial  respiratory  sounds  are 
usually  heard  over  the  same  area.  Vesicular  sounds 
are  alwaj^s.  obscure,  or  wanting.  If  dilatation  of  a 
bronchus  has  occurred,  tubular  or  cavernous  sounds 
may  be  audible. 

The  demonstration  of  displacements  of  the  heart, 
liver,  or  viscera  adjoining  the  lungs  or  thorax  is  ex- 
cellent corroborative  evidence  of  the  existence  of  cir- 
rhosis. If  the  vascular  obstruction  is  considerable  in 
the  lungs,  the  second  cardiac  sound  at  the  pulmonary 
orifice  will  be  accentuated.  When  the  right  ventricle 
is  enlarged  and  hypertrophied,  its  increased  size  can  be 
demonstrated  by  percussion,  and  infra-sternal  pulsations 
can  be  felt. 

Causes. — Cirrhosis  often  occurs  primarily  in  old  age. 
It  is  then  moderate  in  degree  and  generalized.  Few  of 
the  air-cells  are  completely  obliterated,  bnt  most  are 
misshapen,  contracted,  and  surrounded  by  thick,  un- 
3'ielding  walls. 

In  all  other  cases  it  is  secondary  and  usually  to 
chronic  inflammations  of  the  pleura,  lung,  or  bronchi. 
It  is  present,  to  a  greater  or  less  extent,  in  all  cases  of 
chronic  phthisis. 

Treatunent. — The  treatment  consists,  first,  in  obtain- 
ing a  cure  of  the  primnr}^  affection,  or  removal  of  the 
cause;  second,  in  correcting  the  deformit}^  that  the 
lesion  produces,  or  in  compensating  for  it.  Good  hygi- 
ene, and  especially  the  breatliing  of  pnre  air,  is  essential 
to  prevent  fi-esh  irritation  of  the  lungs  and  exacerba- 
tions of  the  trouble.  Pleurisies,  bronchitis,  and  similar 
affections,  which  may  be  the  cause  of  cirrhosis,  are  to 
be  treated  by  customar}'  methods.  To  prevent  the  for- 
mation of  cirrhotic  tissue,  and  even  to  cause  its  disap- 
pearance, the  double  chloride  of  gold  and  sodium,  chlo- 


110  Diseases  of  the  Lungs. 

ride  of  potassium,  and  iodide  of  potassium  and  sodium 
are  commonly  recommended.  I  have  not  been  able  to 
convince  m3'self  of  their  utility,  except  in  one  case, 
where  sj'philitic  inflammation  was  the  cause  of  pulmo- 
nary cirrhosis.     In  tliis  case  the  iodides  were  beneficial. 

To  correct  the  deformities  and  displacements  which 
cirrhotic  tissue  in  the  lungs  causes,  pulmonary  gym- 
nastics are  of  great  utility.  Deep  breathing,  frequently 
resorted  to,  will  often  suffice  to  cause  again  an  expansion 
of  a  retracted  area  of  the  chest.  It  accomplishes  this 
not  by  removing  the  cirrhosis,  but  by  bringing  into  full 
use  man}'  neighboring  air-cells  that  were  before  imper- 
fectl}^  inflated,  because  of  the  weakness  of  the  respira- 
tor}' act,  and,  to  some  extent,  by  producing  a  compen- 
sating emphysema  adjoining  the  cirrhotic  area.  Often 
good  results  are  quickest  obtained  b}'  directing  the 
deep  inhalation  to  be  taken  while  other  parts  of  the 
lungs  than  the  cirrhotic  ones  are  compressed  or  kept 
unexpanded,  so  that  as  much  air  as  possible  can  be 
forced  into  the  affected  areas.  This  mode  of  expanding 
the  lungs  is  especiall}'  applicable  when  the  lower  part 
of  one  lung  is  affected.  By  bending  the  body  to  the 
unaffected  side,  and  retaining  the  position  while  as  deep 
an  inhalation  as  possible  is  taken,  the  retracted  part  of 
the  chest  often  can  be  more  rapidh'  and  perfecth'  re- 
expanded.  When  the  upper  part  of  the  lungs  is  con- 
tracted and  the  thorax  flattened,  exercise  of  the  pectoral 
muscles  and  others  attached  to  tlie  chest,  shoulders, 
and  arms  aid  deep  breathing  in  expanding  the  crippled 
parts.  Pneumatic  differentiation  nnd  residence  at  high 
altitudes  are  especiall}^  useful  to  distend  a  contracted 
thorax. 

Prognosis. — The  prognosis  of  cirrhosis  of  the  lung 
depends  entirely  upon  its  cause.     If  resulting  from  tu- 


Cirrhosis  of  the  Lung.  Ill 

bercular  trouble,  the  prognosis  is  necessarily  governed 
by  the  nature  and  progress  of  the  disease.  If  the  cause 
can  be  removed,  the  lesion  ceases  to  extend,  and  me- 
chanical treatment  ma}'  prevent  permanent  deformity. 
It  is  impossible  to  remove  the  cirrhosis  ;  but  it  may  be 
compensated  for  by  hypertrophy'  or  dilatation  of  the 
lungs. 


CHAPTER  XII. 
Pulmonary  Abscess  and  Gangrene. 

Causes  of  Abscess. — Abscess  of  the  lung  is  not  com- 
mon. Pj'ogenic  matter  deposited  in  tlie  lung  is  essential 
to  its  formation.  Such  matter  may  gain  access  to  the 
pulmonary  tissue  with  foreign  bodies  which  lodge  in  the 
bronchi.  It  frequently  produces  an  abscess  when 
croupous  or  catarrhal  pneumonia  consolidates  the  paren- 
chyma. Oftener  it  gains  access  to  the  lungs  in  septic 
emboli.  The}'  are  produced  in  pysemic  conditions. 
Multiple  pulmonary  abscesses  may  then  be  formed. 
Penetrating  wounds  of  the  thorax  also  rarel}'  admit  it, 
and  are  causes  of  suppuration. 

Anatomy  of  Abscesses. — Abscesses  ma}^  be  formed  in 
either  lung,  and  in  any  part  of  them,  but  they  occur 
oftenest  in  the  upper  lobes.  The}'  vary  greatl}'  in  size, 
— from  almost  microscopic  dimensions  to  cavities  which 
occup}'  an  entire  lobe.  The  cavit}'  is  usually  globular, 
but  ma}'  be  anguhir.  It  contains  pus.  Its  walls  vary 
in  thickness.  Within  they  are  composed  of  numerous 
layers  of  green ish-3'ellow  or  brownish  pus,  and  outside 
of  this  of  granulation  and  fibrous  tissue.  B}-  suppura- 
tion the  lung-tissue  is  destroyed  and  dissolved.  Sup- 
puration may  occur  in  a  lung  consolidated  by  pneumonic 
inflammation  or  by  Intmorihage.  Recovery  may  be 
produced  b}'  a  spontaneous  drainage  and  contraction  of 
the  cavity,  and  ultimate  obliteration  b}'  granulation  upon 
its  inner  surface.  A-'ery  rarely,  small  abscesses  ma}' 
desiccate,  contract,  and  be  transformed  into  cheesy  or 
calcareous  nodules.  More  or  less  complete  spontaneous 
(112) 


.  Pulmonary  Abscess  and  Gangrene.  113 

drainage  is  the  rule.  It  general!}^  occurs  into  a  bron- 
chus, but  may  occur  into  a  pleural  or  into  tlie  peritoneal 
cavity,  where  it  excites  purulent  inflammation.  Yer}' 
rarely,  an  abscess  ruptures  through  the  thoracic  wall. 

Symptoms  of  Abscess. — The  clinical  histor3^  of  pul- 
monary abscess  varies  with  its  origin.  If  it  complicate 
pneumonia  crisis  is  usually  delayed,  or  is  imperfect,  and 
the  fever  soon  rises  again.  Pains  are  felt  in  the  chest, 
and  often  local  bulging  is  recognizable.  Finally,  the 
lesion  manifests  itself  by  a  copious  expectoration  of  pus. 
Abscess  is  to  be  suspected  if  the  patient  has  been 
addicted  to  alcoholics,  or  if  the  pueumonia  has  been  a 
hsemorrhagic  one,  and  a  verj^  purulent  sputa  is  expelled. 

The  sputa  constitutes  the  most  characteristic  symp- 
tom. It  is  usually  abundant,  and  resembles  laudable 
pus.  It  appears  suddenlj-.  If  it  is  not  expectorated 
freely  it  may  become  offensive  in  odor,  but  loses  this 
characteristic  when  it  is  freely  evacuated.  In  chronic 
cases  it  is  rarely  lumpy,  like  the  expectorate  of  phthisis. 
If  allowed  to  stand  it  separates  into  two  la3-ers, — a  lower 
granular  and  an  upper  serous  one.  In  the  pus  particles 
of  lung-tissue,  large  enough  to  be  recognized  by  the  eye, 
are  almost  invariably  present.  Under  the  microscope 
the  bits  of  lung  are  seen  to  consist  of  elastic  fibres, 
which  often  display  the  outline  of  the  alveoli.  Besides 
the  pus-cells,  fat-crystals  and  reddish  pigment-granules 
are  frequently  seen.  Hsematoidin-crj'stals  are  unusually 
abundant.  Micro-organisms  are  numerous  ;  they  are 
chiefly  round,  and  occur  in  groups. 

Often,  at  first,  the  physical  signs  of  pulmonary  con- 
solidation can  be  discovered,  especially  when  the  abscess 
is  superficially  located.  Later,  when  it  is  drained,  the 
signs  of  a  cavit}"  supersede  these. 

Fever,  of  a  hectic  type,  is  almost  invariably  present. 


114  Diseases  of  the  Lungs. 

If  perfect  drainage  is  not  established  spontaneous!}'  or 
artificial! >^  a  pi-ogressive  loss  of  flesh  and  strength 
occurs,  which  finally  ends  in  death. 

Diagnosis  of  Abscess. — A  diagnosis  is  based  upon 
the  history  and  the  i)resence  of  the  characteristic  sputa. 
It  must  beditferentiated  from  (1)  abscess  of  neighboring 
organs, — a^  of  the  liver  or  spine, — which  may  penetrate 
the  lungs  and  be  drained  by  the  bronchi.  Bits  of  lung- 
tissue  cannot  be  found  in  the  sputa  in  these  cases. 
From  (2)  phthisis,  which  is  accomi)lished  by  the  historj^ 
and  by  the  presence  of  tnbercle  bacilli  in  the  sputa  of 
the  latter;  from  (3)  pulmonary  gangrene  by  a  purulent, 
and  at  least  not  constantly  fetid,  sputa,  by  the  absence 
of  mycotic  plugs,  and  a  larger  number  of  haematoidin- 
crystals. 

Causes  of  Gangrene. — As  the  occurrence  of  pulmo- 
nary abscess  requires  the  presence  in  the  lungs  of 
pyogenic  matter,  so,  for  the  i)roduction  of  gangrene,  the 
bacteria  of  putrefaction  must  be  present.  It  is  probable 
that  they  frequently-  enter  the  lungs  in  small  numbers  b}- 
the  bronchi,  but  they  are  unable  to  harm  healthy  tissue. 
Conditions  of  disense  in  the  lungs,  especially  inflamma- 
tions, make  it  possible  for  them  to  develop  gangrene. 
Rarely,  a  healthy  person  may,  by  an  accident,  permit 
putrefiable  matter  to  enter  a  lung, — as,  for  instance, 
particles  of  food  ;  and  with  these  as  a  nidus  gangrene 
may  certninly  develop.  It  will  oftenest  develop  thus  in 
persons  who  are  insane,  delirious,  comatose,  or  whose 
muscles  of  deglntition  are  paralyzed.  .  At  times  bits  of 
decomposing  tissue,  from  cancers  or  ulcers  about  the 
mouth  or  throat,  may  be  drawn  into  the  bronchi  and 
cause  gangrene.  Very  rarely,  ulcers  accompanied  by 
decomposition  may  penetrate  the  thoracic  wall  and 
attack  the  lung,  causing  putrefaction  in  it.     Fetid  bron- 


Pulmonary  Abscess  and  Gangrene.  115 

cbitis  mn}^  also  be  the  cause  of  the  lesion.  Pneumonia 
and  tuberculosis  are  occasionally  complicated  by  gan- 
grene. In  these  cases  the  i)utrefaction  occurs  in  the 
inflamed  tissue,  but  is  not  the  cause  of  it.  Gangrene 
may  be  caused  by  emboli  that  have  been  carried  from 
other  parts  of  the  bod^'  where  decomposition  is  going 
on.  For  instance,  they  may  be  derived  from  extensive 
and  foul  bed-sores  or  abscesses. 

Anatomi/  of  Gangrene. — Either  or  both  lungs  ma}'  be 
attacked.  The  right  one  is  oftenest.  The  lower  lobes 
are  more  liable  to  invasion  than  the  upper.  The  lungs 
may  be  affected  diffusely  and  very  extensivel}^  or  only 
small  parts  of  them  may  be  involved.  Gangrene  often- 
est spreads  from  a  single  focus,  but  may  originate  from 
several.  The  affected  tissue  first  becomes  soft,  and 
brownish  or  greenish  black.  It  exhales  an  offensive, 
fetid  odor.  The  tissue  soon  liquefies  in  part,  and  a 
ragged,  irregular  cavity  is  formed,  which  is  filled  with  a 
greenish-black  fluid  and  bits  of  decomposing  lung.  An 
area  of  catarrhal  or  croupous  inflammation  usually 
exists  about  this  cavity.  The  cavities  commonly  rup- 
ture into  the  bronchi,  but  many  open  into  the  pleura, 
pericardium,  peritoneum,  or,  very  rarely,  externall}^ 
through  the  thoracic  wall.  The  gangrenous  process 
gradually  involves  more  and  more  of  the  contiguous 
tissue.  In  favorable  cases  a  circumscribing  inflamma- 
tion separates  the  necrosed  tissue  from  the  rest  as  a 
sequestrum,  and  forms  a  limiting  wall  around  it.  The 
latter  may  be  thin  or  thick,  and  in  time  may  become 
fibrous.  Extensive  h.nemorrhage  is  rare,  as  it  is  pre- 
vented by  coagulation  within  the  pulmonary  vessels 
before  they  are  destroyed.  If  the  cavity  is  thoroughly 
emptied  of  its  putrefying  contents,  the  fibrous  capsule 
usually  contracts  it.     The  granulation  tissue  by  which 


116  Diseases  of  the  Lungs. 

it  is  lined  may  cause  its  final  obliteration.  Pleiirisj'  is 
a  common  complication  of  gangrene,  and  is  often 
purulent. 

Symjytoms  of  Gangrene. — Tlie  symptoms  which  ac- 
company gangrene  vary  much.  As  it  is  often  secondary, 
the  symptoms  of  the  primary  aft'cction  may  obscure  those 
that  are  due  wholly  to  the  gangrene.  In  such  cases  the 
sputa  affords  the  most  characteristic  signs  of  the  disease. 
It  is  often  large  in  amount.  It  may  be  as  much  as  fifteen 
to  twenty  ounces  per  diem.  It  resembles  in  physical 
attributes  the  sputa  of  fetid  bronchitis.  Its  odor  is 
extremely  offensive.  It  taints  the  breath  of  the  patient, 
and  even  the  air  about  him  for  many  feet.  If  allowed  to 
stand  it  stratifies,  as  does  the  sputa  of  fetid  bronchitis. 
In  the  lowermost  la3'er  pus-cells  and  granular  matter 
predominate,  but  plugs  and  shreds  of  tissue  can  also 
be  found  in  considerable  amounts.  The  plugs  contain 
numerous  crystals  of  fatty  acid  imbedded  in  countless 
bacteria.  But  what  distinguishes  this  from  the  sputa 
of  fetid  bronchitis  is  the  particles  of  lung-tissue  which 
can  be  found  in  it.  Various  chemical  substances  are 
produced  by  the  putrefaction  which  are  characteristic 
of  it.  In  very  rare  cases  upon  the  post-mortem  table 
gangrene  of  the  lungs  is  demonstrated,  though  never 
suspected  before  death,  for  the  characteristic  sputa  and 
foetor  oris  were  wanting. 

Tlie  other  symptoms  are  not  peculiar  to  it.  Cough 
and  ])ain  in  the  side  are  usual.  Dj'spnoea  is  sometimes 
marked.  Centrally- located  gangrene  does  not  mod  if}' 
the  physical  signs,  but  when  it  is  superficial  and  exten- 
sive, at  first,  the  signs  of  pulmonary  consolidation, and, 
later,  of  pulmonary  excavation  are  demonstrable.  The 
signs  of  pleurisy  are  frequently  present,  and  may 
obscure  the  others, 


Pulmonary  Abscess  and  Gangrene.  lit 

Fever  usually  exists,  but,  as  a  rule,  it  is  quite  irregu- 
lar. If  the  gangreuous  slough  is  freely  eliminated  from 
an  encapsuled  cavity  and  absorption  is  thus  prevented, 
fever  msij  be  absent. 

The  foetor  of  the  breath  often  destroys  the  patient's 
appetite  and  ma^'  even  cause  vomiting.  The  absorption 
of  putrefying  matter  rarely  causes  rheumatoid  pains. 
Metastatic  abscesses  may  result  from  gangrene.  Death 
has  often  been  immediatel}'  caused  bj'  a  secondary 
abscess  of  the  brain. 

A  diagnosis  can  only  be  made  when  the  character- 
istic sputa  is  present. 

Prognosis  of  Pulmonary  Abscess  and  Gangrene. — The 
prognosis  of  pulmonary  abscess  must  be  a  guarded  one. 
It  is  always  a  grave  disease.  But  a  large  proportion 
of  the  cases  that  occur  are  curable.  A  small  proportion 
recover  spontaneously.  They  are  those  in  which  the 
abscess  is  thoroughly  drained  b}'  the  bronchi  or  by 
rupture  through  the  thoracic  walls. 

Diffuse  gangrene  of  the  lungs  is  rarely  recovered 
from.  Circumscribed  gangrene  may  be.  It  must  always 
be  remembered,  however,  that  infection  of  other  parts 
of  the  lungs  may  occur  so  long  as  any  gangrene  remains. 
Death  is  the  result  either  of  general  loss  of  strength 
or  of  complications,  such  as  pulmonar}^  haemorrhage, 
pleurisy,  and  brain-abscess. 

Both  in  abscess  and  gangrene  of  the  lungs  the 
prognosis  will  depend,  in  part,  also,  upon  the  vigor 
of  the  patient  or  the  existence  of  other  underlying 
disease. 

Treatment  of  Abscess  and  Gangrene. — Gangrene  may 
be  prevented  by  removing  food  from  the  air-passages  if 
it  accidentally  fall  into  them  when  the  muscles  of  deglu- 
tition are  partly  paralyzed,  or  a  patient  is  mentally  dull. 


118  Diseases  of  the  Lungs. 

Persons  who  are  thus  liable  to  errors  of  swallowing 
should  be  closely  watched  while  eating. 

In  abscess,  if  the  sputa  is  offensive,  and  always  in 
gnngrene,  much  beuelit  cau  be  derived  from  the  inhala- 
tion of  antiseptics.  The  best  effects  are  obtained  by 
the  prolonged  inhalation  of  them.  Therefore,  antise})- 
tics  are  best  administered  by  a  respirator,  which  should 
be  worn  for  hours.  Turpentine,  oil  of  pine,  eucalyptus, 
beech-wood  creasote,  and  carbolic  acid  are  among  the 
most  useful  antiseptics.  Inhalation  through  the  res- 
pirator may  at  first  cause  a  feeling  of  oppression,  but 
this  will  pass  otf  as  the  user  becomes  accustomed  to  it. 
Simpler  means  of  inhalation,  though  less  certainly  use- 
ful, may  be  employed.  For  instance,  the  vapors  of  tur- 
pentine or  of  creasote,  or  of  eucalyptus,  ma}'  be  inhaled 
from  a  pitcher  in  which  they  have  been  mixed  with 
steaming  water,  In^  fitting  a  paper  cover  over  the 
pitcher  for  a  mouth-piece.  Or  a  Florence  flask  with 
an  air-inlet  and  iuhaling-tube  may  be  employed.  When 
such  antiseptics  are  inhaled  the}'  not  oidj-  check  the 
putrefaction,  but  also  check  suppuration.  The  pro- 
longed use  of  the  mask  or  respirator  insures  the 
impregnation  of  all  the  air  in  the  lungs  by  them. 

Sym[)tomatic  treatment  may  be  needed  to  relieve 
pleuritic  pains,  or  to  allay  nausea  and  vomiting.  The 
radical  treatment  for  abscess  and  gangrene  of  the  lungs 
is  surgical.  Success  can  usuall}*  be  expected  from  it. 
Abscesses  should  be  drained  as  soon  as  the}'  can  be 
located.  The  drainage  should  be  as  thorough  as  pos- 
sible. It  is  often  impossible  to  wash  the  abscess-cavity 
through  a  drainage-tube,  because  the  lungs  are  very 
liable  to  be  flooded  by  the  injected  fluid,  since  bronchi 
mIso  usually  communicate  with  it.  A  large  proportion 
of  cases,  if  opened   by  puncture  or  incision   and  well 


Pulmonary  Abscess  and  Gangrene.  119 

drained,  will  recover.  Occasional!}^  a  fistula  will  be  left. 
In  one  case,  under  m}^  own  observation,  a  fistula  per- 
sisted for  more  than  a  year,  but  was  finally  obliterated. 
Recourse  to  the  same  surgical  procedures  affords  almost 
the  only  hope  of  successfully  treating  gangrene  of  tlie 
lungs.  Many  cures  have  been  effected  by  incision  and 
drainage.  To  give  a  patient  the  best  possible  chance, 
resort  should  be  had  to  this  method  of  treatment. 

In  both  diseases  the  individual's  strength  should  be 
conserved  as  much  as  possible.  Rest  should  be  main- 
tained, both  to  prevent  the  employment  of  strength  un- 
necessaril}'  and,  at  least  in  gangrene,  to  more  perfectly 
prevent  the  spread  of  the  gangrene  to  other  parts  of  the 
lungs,  which  might  be  caused  by  constantly  var3'ing  the 
body's  position.  The  appetite  should  be  stimulated  by 
bitter  tonics  when  it  is  deficient,  and  digestion  aided  if 
it  is  imperfect.  Food,  under  all  circumstances,  should 
be  given  with  regularit}^,  and  in  amounts  suflficient  to 
maintain  general  strength.  The  kinds  of  food  to  be 
employed,  and  their  amounts,  must  be  varied  according 
to  the  condition  of  the  patient's  appetite  and  powers  of 
digestion. 


CHAPTER  XIII. 

Pulmonary  Tuberculosis. 

Definition. — Pulmonary  tuberculosis,  or  phthisis,  is 
a  specific  inflammiitioii  of  the  bronchi  and  lungs.  It  is 
excited  by  the  bacillus  tuberculosis.  The  specific  inflam- 
mation is  always  associated  with  simple  inflammation, 
and  usuall}'  with  suppurative  inflammation.  It  is  a 
wasting  disease,  and  commonly  a  chronic  one. 

Anatomy. — The  anatomical  changes  which  are  ob- 
served in  the  lungs  of  those  affected  with  tubercular 
disease  vary  greatly.  The}'  ma}^  be  extensive,  or  slight, 
catarrhal,  croupous,  or  interstitial  inflammations.  The 
lung  is  at  first  consolidated,  and  hiter  excavated.  While 
the  anatomical  lesions  are  so  various,  there  are  certain 
ones  always  present  and  characteristic ;  the}'  are  the 
tubercle-nodules.  Miliary  tubercles  are  usually  present. 
Infiltrating  tubercular  tissue  may  also  exist.  The 
characteristics  of  the  miliary  tubercle  are  the  formation 
by  cells  of  a  globular  mass  the  size  of  very  small  shot. 
This  body  is  composed  of  large  numbers  of  small  round- 
cells.  Near  its  centre  are  larger,  oval,  epithelioid,  and 
giant  cells.  To  some  extent  within  the  cells,  and  more 
abundantly  between  them,  tubercle  bacilli  cnn  be  seen. 
No  new  blood-vessels  are  formed  in  these  nodules. 
When— and  sometimes  before— it  attains  its  minute 
growth  the  cells  at  its  centre  lose  their  vitality,  degen- 
erate, and  become  a  shapeless  mass  of  dry  fat-granules. 
This  degeneration  and  desiccation  constitute  caseation. 
At  first  the  miliary  tubercles  are  gray  and  gelatinous, 
but  soon  become  yellowish. 
(120) 


Pulmonary  Tuberculosis.  121 

These  minute  masses  may  coalesce  and  form  larger 
ones,  which  are  sometimes  called  tubercle-nodules. 
Irregularly  shaped  or  disposed  lines  of  caseous  material 
are  also  often  observable.  They  may  be  made  by  the 
coalescence  of  miliary  tubercles,  but  they  may  also  be 
made  by  the  degeneration  of  tissue  that  is  infected  by 
the  tubercular  poison.  It  is  probable  that  some  sub- 
stance formed  b}^  the  bacilli  so  affects  the  tissue-cells 
that  they  degenerate.  The  absence  of  capillaries,  be- 
cause of  the  non-formation  of  them  in  the  inflammatory 
tissue  and  the  frequent  obliteration  of  them  in  old 
tissue,  leads  to  the  drying  or  caseation  of  the  degen- 
erated mass.  The  tendency  to  degenerate,  though  origi- 
nating usually  in  a  miliary  tubercle,  spreads  from  them, 
when  they  are  completely  involved,  to  the  surrounding 
structures,  providing  the  bacilli  continue  growing 
actively. 

Tubercles  are  the  foci  of  extensive  simple  inflamma- 
tion, or  they  render  chronic  what  was  at  first  a  simple 
inflammation.  For  example,  around  a  miliary  tubercle 
there  may  arise  bronchitis,  catarrhal  or  croupous  pneu- 
monia, and  where  tuberculosis  infects  the  lungs,  because 
of  an  existing  bronchitis,  it  may  make  the  latter  chronic. 
Infection  most  frequently  occurs  first  in  the  small 
bronchi,  where  a  miliary  tubercle  is  formed.  It  excites 
a  catarrhal  inflammation  of  the  mucous  membrane,  as 
well  as  inflammation  of  the  submucosa  and  deeper  tissues 
of  the  bronchi.  This  may  lead  to  several  diff"erent 
results  : — 

1.  Atelectasis  mny  be  produced  if  the  inflammation 
and  catarrhal  desquamation  produce  obstruction  to  the 
minute  bronchi.  A  patch  of  consolidation,  lobular  in 
size,  will  thus  be  formed.  Soon,  in  the  wall  of  some  of 
the  collapsed  alveoli,  miliary  tubercles  will  develop,  and 

6    F 


122  Diseases  of  the  Lungs. 

excite  more  extensive  round-celled  infiltration  into  the 
alveoli  and  interstitial  tissue.  In  some  of  the  collapsed 
air-cells  catarrhal  inflammation  will  be  excited,  and  the}^ 
will  be  filled  with  epithelial  cells.  Thus  a  tubercle- 
nodule  is  formed. 

2.  Instead  of  this  course  the  localized  tubercular 
capillary  bronchitis  ma}-  lead  to  peribronchitis  and 
catarrhal  pneumonia.  The  solidified  tissue  in  this  case, 
also,  is  lobular  in  size.  It  resembles  in  all  ways  the 
lesion  of  catarrhal  pneumonia,  except  that  it  is  infected 
by  tubercle  poison,  and  miliary  tubercles  ma3^  be  formed 
in  it,  or  it  becomes  extensively  caseous  under  the  influ- 
ence of  the  bacilli. 

3.  Croupous  inflammation  of  the  lung  ma}'  be  ex- 
cited. Oftenest  the  fibrinous  consolidation  is  very 
limited  in  extent,  but  it  ma}^  be  extensive  enough  to 
involve  an  entire  lobe. 

4.  To  some  extent  in  all  cases,  but  especially  in  the 
most  chronic  cases,  do  the  interstitial  tissues  become 
inflamed.  Such  inflammation  produces  broad  bands  of 
fibrous  tissue.  Tubercle-nodules  and  lung-cavities  are 
frequentl}' encapsuled  b}- them.  Cirrhotic  inflammation 
is  usually  protective,  because  it  tends  to  encnpsule,  and 
thus  to  limit  the  spread  of  the  tuberculous  infection.  It 
helps  to  contract  and  to  obliterate  cavities.  It  produces 
the  contraction  of  the  lungs  which  is  characteristic  of 
chronic  phthisis.  In  the  fibrous  tissue  tubercle  bacilli 
are  very  rare.  It  may  almost  be  said  that  they  do  not 
exist  in  it.  Apparently  it  is  a  barrier  to  their  dissemi- 
nation through  the  lungs.  New  connective  tissue  may 
encapsule  a  caseous  nodule  of  any  size  and  isolate  it. 
All  the  cells  containing  bacilli  finally  degenerate;  the 
bacilli  die  and  disappear,  and  the  caseous  mass  is  thus 
rendered  inert.     It  will  then  usually  calcify,  and  may 


Pulmonary  Tuberculosis.  123 

remain  in  the  lung-  indefinitely  and  liarnilessl3\  Such 
protective  capsules  are  not  perfectly  developed  except 
in  the  chronic  cases. 

5.  Ulceration  of  the  bronchi  may  result  from  their 
primary  infection.  Caseation  in  a  bronchial  tubercle 
will  spread  through  it  until  the  submucosa  is  involved 
and  the  epithelium  cast  off.  The  cheesy  matter  will 
crumble  off  into  the  bronchus,  and  a  loss  of  substance 
will  be  rapidly  caused.  Suppurative  inflammation  then 
sets  in,  and  the  bronchial  wall  is  quickly  eroded.  A 
minute  cavity  is  thus  formed.  A  large  one  may  be  pro- 
duced rapidl}^  by  the  coincident  destruction  of  tissue  by 
caseation  and  suppuration. 

6.  Pleurisy  is  always  excited  when  inflammation 
occurs  immediately  beneath  the  pleura.  The  latter  is 
thickened.  Adhesions  between  the  pleural  surfaces 
always  exist  when  tubercular  disease  is  widely  diffused 
in  the  lungs,  and  often  so  extensively  that  the  pleural 
sac  is  obliterated.  The  pleurisy  which  accompanies 
phthisis  is  usually  dry.  In  a  moderate  proportion  of 
cases  it  is  serous,  and  rarely  it  is  purulent.  Miliary 
tubercles  may  form  in  the  thickened  pleura,  but  do  not 
uniformly.  Serous  effusion  occasionally  occurs  into  the 
pleural  cavity  or  into  a  part  of  it  that  has  been  divided 
off  by  preceding  dry  pleurisy. 

Cavities  are  formed  in  two  ways  in  phthisis  :  (1)  b}^ 
softening  and  excavation  of  tissues  consolidated  by 
catarrhal  or  croupous  pneumonia ;  (2)  by  the  dilatation 
of  bronchi  and  their  erosion  through  suppuration.  The 
pathology  of  bronchi ectatic  cavities  I  need  not  repeat. 
(See  page  5if.)  The  influence  of  tubercle  bacilli,  or  the 
chemical  products  of  their  life,  is  to  cause  fatty  degener- 
ation and  caseation.  This  tendency  is  increased  by  the 
non-vascular    character    of    tuberculous    inflammation. 


124  Diseases  of  the  Lungs. 

Softening  and  snppiiration,  though  exceedingh'  common 
in  caseous  nodules  in  the  lungs,  is  not  as  common  in  simi- 
lar formations  in  other  organs.  It  is  undoubtedly  true 
that  softening  and  suppurative  inflammation  of  consoli- 
dated and  caseous  portions  of  the  lungs  is  often  due  to 
a  superimposed  infection  by  pyogenic  agents.  The 
latter  is,  then,  the  cause  of  liquefaction  of  the  nodule. 
Koch's  experiments  with  tuberculin  show  that  chemicals 
the  products  of  the  growth  of  the  bacillus  tuberculosis 
ma}'  also  cause  suppuration.  The  softening  usually 
takes  place  first  in  the  centre  of  the  mass.  This  is 
especially  true  if  originally  a  bronchiole  passed  through 
its  centre.  The  softening  sometimes  begins  about  the 
margins  of  a  caseous  nodule.  At  first  the  puriform 
fluid  is  odorless,  thin,  and  contains  few  pus-cells,  but 
large  amounts  of  granular  matter.  Such  pus  is  doubtless 
the  result  of  tubercular  infection  only.  Later,  and 
especially  after  the  cavity  has  opened  into  a  bronchus, 
and  it  has  become  infected  by  the  commoner  pyogenic 
organisms,  its  contents  are  characteristic  pus  which  is 
often  more  or  less  fetid.  Minute  cavities  thus  formed 
soon,  by  their  growth,  open  into  a  bronchus  and  empty 
in  part  or  wholly.  The}^  grow,  as  do  other  abscesses,  by 
the  degeneration  and  desquamation  of  the  granulation 
cells  that  compose  their  wall.  Bronchiectatic  and  other 
cavities  in  tuberculous  lungs  enlarge  more  rapidh'  be- 
cause of  the  caseation  which  takes  place  here  and  there 
in  their  walls  under  the  influence  of  the  tubercle  bacilli. 
For  granular,  cheesy  nintter,  when  laid  bare,  will  rapidl}^ 
crumble  into  a  cavity  and  niaj-  produce  a  considerable 
loss  of  substance.  After  communication  has  been 
estal)lished  with  a  bronchus,  the  air-pressure  within  the 
cavity  is  an  important  factor  in  enlarging  it,  for  its 
walls  are    not    firm,  as   a   rule,  and    may   be    stretched. 


Pulmonary  Tuberculosis.  125 

Cavities  frequently  rupture  into  one  another.  Small 
cavities  are  usuall}^  irregular  in  shape ;  large  ones  are 
more  frequently  smooth  witliin.  Bat  both  vary  greatly 
in  these  respects.  Cavities  almost  invariably  form  first 
in  the  upper  lobes  ;  the}'  mfvy  be  numerous  or  there 
may  be  but  one.  In  man}'  instances  numerous  caseons 
nodules  are  observable  between  the  cavities  and  the 
surface  of  the  lung.  As  the  excavations  extend  near  to 
the  pleura  it  is  inflamed,  and  firm  adhesions  usuall}^ 
form  between  the  pleural  surfaces  over  cavities.  A 
cavit}^  may  occupy  the  whole  of  one  lobe,  and  be  nearly 
as  large  as  an  infant's  head.  Bands  of  tissue  often  pass 
across  them.  These  are  usuall}^  parts  of  the  interlobular 
septa,  and  they  may  include  arteries  of  considerable  size. 
The  latter  are  usually  obstructed  by  clots,  but  may  be- 
come aneurismal  and  by  rupture  cause  violent  or  fatal 
hgemorrhage.  About  all  old  cavities  a  fibrous  envelope 
forms ;  if  the  cavity  is  perfectly  drained  this  envelope 
may  cause  its  contraction  and  even  obliteration,  pro- 
vided the  inner  granulating  surfaces  of  its  walls  can  be 
brought  in  contact  long  enough  for  adhesion  to  be  pro- 
duced. Small  cavities  whose  outlet  becomes  obstructed 
are  rarely  obliterated  by  the  absorption  of  their  fluid 
contents,  by  the  contraction  of  their  walls,  and  by  the 
caseation  or  calcification  of  their  solid  contents.  Un- 
fortunately, this  is  not  the  usual  course  of  pulmonary 
cavities  ;  they  must  be  expected  to  enlarge.  The  con- 
traction of  a  cavit}'  necessitates  a  compensatory  dilata- 
tion or  displacement  of  neighboring  lung-tissue.  There- 
fore the  lung  is  often  drawn  upward  from  this  cause,  and 
if  pleuritic  adhesions  are  extensive  other  organs  ma}-  be 
displaced.  The  contents  of  the  cavities  are  pus,  granular 
and  oily  matter.  In  all  that  are  rapidly  enlarging  bits 
of  the  elastic    frame-work  of  the   luno'  can   be  found. 


126  Diseases  of  the  Lungs. 

Tubercle  bacilli  and  various  micrococci,  pus-forming 
and  iion-patliognomonic,  are  discoverable  in  them. 

The  capillaries  in  tubercularl}' -inflamed  tissues  be- 
come occluded,  and  new  vessels  do  not  form.  The  calibre 
of  the  larger  arteries  is  sometimes  diminished  or  oblit- 
erated b}'  endarteritis.  Occasionally  small  patches  of 
hyaline  degeneration  can  be  observed  in  phthisical  lungs. 
This  change  is  usually  limited  to  the  fibrous  tissues  or 
the  blood-vessels. 

The  various  lesions  that  have  been  described  are 
combined  in  many  ways.  Oftenest  caseous  nodules  of 
catarrhal  pneumonia  are  seen  scattered  through  the 
lungs.  Usuall}'  cavities  are  also  observable  at  the  apex. 
If  the  given  case  has  been  a  chronic  one,  much  connect- 
ive tissue  will  be  found  about  the  lesions  at  the  apex, 
while  in  the  lower  lobe  more  recent  nodules  of  catarrhal 
pneumonia  will  be  observed.  Or,  if  life  has  ended  from 
an  acute  exacerbation  of  disease,  one  lobe  may  be  found 
consolidated  by  croupous  pneumonia.  Caseous  nodules, 
or  more  diffuse  masses  of  caseous  material,  will  also  be 
seen  in  it. 

The  tubercle  bacillus,  and,  therefore,  the  cause  of 
the  characteristic  lesions,  is  disseminated  through  the 
lungs  by  three  channels  :  by  the  blood,  by  the  lymphat- 
ics, and  by  the  bronchi.  In  most  cases  dissemination 
occurs  b}^  both  the  last-named  channels,  and  often  hy 
all  tiiree.  In  miliarv  tuberculosis  the  lesion's  cause  is 
always  spread  by  the  blood-vessels.  In  man3'  chronic 
cases  a  few  miliary  tubercles  will  be  found  in  the  intes- 
tines. They  are  probably  caused  by  infection  from 
sputa  that  has  been  sw\allowed.  More  rarely  other 
organs  will  contain  them,  which  must  have  been  in- 
fected through  the  blood.  Infectious  material  is  usually 
not  carried  far  by  the  lymph.    It  may  be  conveyed  from 


Pulmonary  Tuber^culosis,  127 

one  part  of  a  lobe  to  another  part,  and  especiall}'  toward 
the  hilus.  The  bronchial  glands  thns  become  involved. 
But  it  is  not  [)robable  that  the  bacilli  are  transmitted 
by  these  channels  from  one  lobe  to  another,  and  cer- 
tainl}'  not  from  one  lung  to  the  other.  The  bronchial 
tubes  are  most  frequently'  the  channels  of  dissemination. 
The  sputa  is  its  carrier.  Sputa  is  not  always  expelled 
when  it  is  moved  in  the  bronchi,  but  is  often  drawn 
back,  and  even  carried  into  the  lung-tissue,  by  the  air- 
currents.  J.  K.  Fowler  has  recently  demonstrated 
quite  conclusively  the  usual  path  of  infection  by  the 
bronchi.  Oftenest  the  primary  trouble  is  at  one  apex. 
The  difference  in  the  susceptibility  of  the  lungs  is 
slight:  the  left  is  probably  first  affected  a  little  the 
oftenest.  The  lesion  does  not  develop  absolutely  at  the 
apex,  but  an  inch  or  thereabouts  below  it  ;  or  else, 
opposite  a  point  on  the  exterior  of  the  chest,  just  below 
tlie  outer  third  of  the  clavicle.  The  lesion  is  also  usu- 
ally nearer  the  posterior  surface  of  the  lung  than  the 
anterior.  Before  the  opposite  lung  is  involved  the  top 
of  the  lower  lobe  on  the  side  first  infected  becomes  the 
seat  of  a  lesion.  The  opposite  lung  is  tlien  attacked, 
and  generally  its  different  parts  are  involved  in  the 
same  order.  The  middle  lobe  is  last  involved,  and 
often  escapes  entirely. 

The  primary  lesions  near  the  apices  of  the  upper 
and  lower  lobes  increase  in  size  and  extend  particularly 
downward.  New  nodules  also  form  close  by,  and,  grow- 
ing, finally  unite  with  the  first  ones.  In  this  way  the 
solid  mass  increases.  It  has  often  a  rudely-triangular 
shape,  the  triangle's  base  being  the  primary  nodule,  the 
apex  being  downward  and  the  anterior  border  parallel, 
and  usually  coinciding  with,  the  anterior  surface  of 
the  lung  in  the  upper  lobe  and  the  interlobular  septum 


128  Diseases  of  the  Lungs. 

in  the  lower.  Beneath  these  Uirgest  solid  masses  smaller 
discrete  ones  can  be  found. 

The  way  in  which  the  diverse  lesions  of  phthisis  are 
produced  is  not  perfectl}^  clear.  Undoubtedly  the 
bacillus  tuberculosis  causes,  b3'  its  presence  or  b}^  the 
products  of  its  vitality,  miliary  tubercles  and  diffuse 
tubercular  tissue.  The  catarrhal  and  peribronchial 
pneumonias  are  the  results. of  the  extension  of  inflam- 
mation which  accompanies  or  surrounds  wiiat  is  strictly 
tubercular.  The  interstitial  inflammation  is  undoubt- 
edly chiefly  conservative.  The  presence  of  tubercle 
bacilli,  or,  more  probabl}',  of  the  chemical  products 
made  by  them,  leads  to  caseation.  It  is  not  common 
for  tubercular  lesions  elsewhere  than  in  the  lungs  to 
suppurate ;  when  they  do,  other  microbes  than  the 
tubercular  are  found  in  the  pus  and  inflamed  tissue.  It 
is  therefore  not  clear  that  suppuration  of  tubercularly- 
inflamed  tissue  is  often  due  to  the  tubercular  infection 
onl}'.  The  tubercular  inflammation  excites  general 
symptoms  as  well  as  local  ones.  The  former  are  very 
like  those  of  a  chronic  septicaemia.  This  is  especially 
true  after  suppuration,  when  usually  a  genuine  septi- 
caemia exists. 

Miliary  tuberculosis  of  the  lungs  develops  when  the 
blood  is  infected.  The  miliary  tubercles  will  then 
develop  simultaneous!}'  in  most  of  the  organs  and 
tissues  of  the  bod}-.  The  disease  is  a  general  one,  and 
not  strictly  one  of  the  lungs.  In  such  cases  the  tuber- 
cles are  uniformly  scattered  through  the  lungs.  Thej* 
may  be  so  numerous  as  to  fill  a  large  part  of  the  lung- 
tissue,  or  the}^  may  not  be  at  all  numerous.  They  ma}' 
coalesce  to  form  small  nodules. 

The  lesions  of  so-called  acute  i)ulmonary  phthisis 
do  not  differ  from  those  of  the  chronic  form,  except  in 


Pulmonary  Tuberculosis.  129 

the  rapidity  with  which  they  develop  and  spread. 
Fibrous  tissue  is  rareh'  developed,  or,  at  least,  to  an3' 
considerable  extent.  Miliary  tubercles  may  not  be 
present.  Often  one  entire  lobe  is  consolidated  and 
extensivel}'  caseated  or  excavated.  The  lesions  may  be 
catarrhal  or  croupous,  or  both.  They  caseate  with 
rapidity,  and  cavities  form  in  them  as  quickly.  Gan- 
grene not  unfrequently  supervenes. 

Symptoms. — In  chronic  tubercular  disease  of  the 
lungs  tliree  stages  are  recognized  clinically  :  a  stage  of 
incipient  tuberculosis  ;  a  stage  of  consolidation  ;  a  stage 
of  softening  and  excavation.  The  first  is  anatomically 
characterized  by  a  localized  bronchitis,  usually  in  one 
or  both  apices,  and  by  consolidation  too  small  in  amount 
to  recognize  clinically  ;  the  second  by  clearly  recogniz- 
able consolidation ;  the  third  by  the  formation  of 
cavities. 

In  the  first  stage  the  ph3^sician  maj^  be  consulted 
either  for  a  gradual  loss  of  flesh  and  strength  or  for  a 
persistent  cough.  Frequently,  an  acute  bronchitis, 
which  becomes  chronic,  tliough  mild,  is  the  origin  of 
the  disease.  An  insidious  loss  of  strength,  which  causes 
lassitude  and  loss  of  flesh  and  color,  are  characteristic. 
The  face  grows  gray  or  sallow,  tliough  the  lips  remain 
red.  The  patient  tires  quickly.  His  respirations  are 
short  and  quick  on  slight  exertion,  and  even  when  at 
rest  the  movements  are  shallower  than  is  normal  or 
they  are  unequal  on  the  two  sides.  There  is  usuall}^  a 
slight,  constant,  hacking  cough  ;  the  coughing  is  now 
and  then  aggravated  by  a  fresh  cold.  Often  the  appe- 
tite and  digestion  remain  normal,  but  sj^mptoms  of 
dyspepsia  are  not  unusual.  The  pulse  is  quick,  var3^ing 
from  90  to  100  per  minute.  The  temperature  is  slightly 
raised  :  when  the  bronchitis  is  severe  it  may  be  102°  or 


130  Diseases  of  the  Lungs. 

103^  F.,  but  usuall}'  it  is  about  100^  F.  by  eight  o'clock 
in  the  evening,  when  it  reaches  its  maximum.  It  is 
normal  in  the  early  morning  hours.  Xot  uufrequentl}^ 
a  sense  of  chilliness  is  experienced  about  the  middle  of 
the  forenoon,  and,  rarely,  an  actual  rigor  occurs.  When 
the  bronchitis  is  severe  considerable  sputa  may  be  ex- 
pectorated. It  is  in  tiie  early  morning  commonly  muco- 
purulent, and  later  in  the  day  frothy  mucus;  but  the 
commoner,  persistent,  hacking  cough  is  dry.  In  the 
sputa  tubercle  bacilli  can  be  discovered  if  patiently 
sought  for.  Haemopt^'sis  may  occur.  Bleeding  at  this 
stage  is  small  or  moderate  in  amount ;  it  does  not  occur 
in  half  the  cases. 

The  physical  signs  are  most  characteristic  in  those 
who  inherit  a  predisposition  to  tubercular  disease.  We 
discover  this  stage,  usualh',  developing  in  bo^-s  and 
girls  between  the  ages  of  14  and  22.  The}'  are  slender; 
their  muscles  are  small  and  weak;  their  skin  is  thin  and 
white  ;  the  chest  is  long,  narrow,  and  thin  ;  often  the 
head  droops  forward  or  the  shoulders  bow  ;  the  anterior 
and  upper  surface  of  the  chest  is  flat,  and  expands  very 
moderatel}'  with  inspiration.  In  those  in  whom  the 
predisposition  is  acquired  in  adult  life  the  shape  of  the 
chest  is  not  characteristic.  Respiration  becomes  shal- 
low, and,  usuall}^,  especially  so  upon  one  side.  There  is 
no  abnormal  fremitus.  The  apices  are  less  resonant 
than  is  natural,  but  localized  dullness  is  not  dfscover- 
able.  The  respiratory  sounds  are  not  uniform  over  the 
chest :  they  may  be  exaggerated  at  both  apices,  but 
more  frequently  the}-  are  not  uniform  upon  the  two 
sides  ;  for  instance,  in  the  left  supra-clavicular  region 
inspiration  may  be  loud,  in  the  infra-clavicular  and 
supra-scapular  regions  it  may  be  loud  and  often  hitching. 
There  is  no  expiratory  sound.     Over  the  lower  part  of 


Pulmonary  Tuberculosis.  131 

the  left  lung  the  sounds  ma}'  be  clear  and  purely 
vesicular,  but  over  the  right  apex  the  sounds  ma}^  be 
low,  and  near  the  outer  end  of  the  clavicle  the^'  maj'  be 
absent ;  a  prolonged  expiratory  sound  may  be  heard. 
Over  the  lower  part  of  this  lung  the  sounds  will  probabl}' 
be  low,  vesicular.  It  must  not  be  supposed  that  the 
respiratory  sounds  are  alwa3's  just  as  described  in  this 
illustration.  The  characteristic  of  them  is  rather  a 
marked  difference  upon  the  two  sides,  and  even  in 
different  parts  of  the  same  side,  and  especially  an  abnor- 
mality in  the  sounds  at  one  or  both  apices. 

In  the  second  stage  of  the  disease  the  bronchitis  is 
more  severe.  Coughing  occurs  often,  and  is  alwa3'S  a 
noticeable  symptom,  while  in  the  first  stage  it  is  often 
so  slight  MS  to  be  overlooked  by  the  patient.  The 
expectorate  is  more  constantly  muco  purulent,  and 
bacilli  are  more  numerous.  Often,  in  acute  exacerba- 
tions, the  usual  symptoms  of  acute  bronchitis  will  be 
present.  Emaciation  goes  on  more  rapidh',  and  the 
patient  is  more  languid.  The  appetite  is  often  lessened 
and  capricious.  The  pulse  remains  quick,  is  smaller 
and  softer.  The  temperature  follows  the  same  course 
as  in  the  earlier  stage,  but  averages  a  degree  higher  by 
eight  o'clock  in  the  evening,  and  is  usuall}^  a  little  sub- 
normal in  the  earliest  morning  hours.  Sweating  at 
night  may  occur  in  the  first  stage,  but  less  often  thjin 
now.  Respiration  is  shallower,  and  decided!}'  so  upon 
one  side  of  the  thorax.  It  is  more  easil}'  excited,  and 
breathlessness  on  exertion  is  greater. 

On  inspection,  the  difference  in  the  freedom  of  ex- 
pansion of  the  two  sides  is  evident.  Often,  especially  in 
the  chronic  cases,  the  supra- and  infra- clavicular  regions 
upon  one  side  will  be  more  retracted  than  upon  the 
other.     Yocal  fremitus  is  increased  over  these  retracted 


132  "  Diseases  of  the  Lungs. 

area.s.  At  these  points  there  is  greater  relative  dull- 
ness, but  nowhere  is  there  absolute  dullness.  Over  these 
same  areas  the  respiratory  sounds  are  broncho-vesicular. 
Moist  rales  can  occasional!}'  be  heard.  These  evidences 
of  lung  consolidation  ma}'  not  be  confined  to  one  apex, 
but  may  be  elicited  over  areas  of  either  lung,  or  different 
parts  of  each.  The}'  are  discoverable,  usually,  at  the 
apices,  or  posteriorly  at  the  top  of  the  lower  lobes. 
Over  other  parts  of  the  lungs  tlie  physical  signs  may  be 
normal,  or  those  of  bronchitis  only. 

In  the  third  stage  of  the  disease  the  emaciation  is 
often  extreme.  The  cheeks  are  "hollow.  If  the  invalid 
attempts  to  sit  up,  the  back  quickly  bows  and  the  shoul- 
ders sag.  Speech  is  frequently  slow.  There  is  little 
endurance,  and  sooner  or  later  the  patient  is  bedridden. 
The  pulse  grows  smaller  and  remains  soft  and  quick. 
The  temperature  varies  much  from  day  to  day,  but  aver- 
ages 102°  F.  at  night,  and  is  almost  uniformly  subnormal 
in  the  early  morning.  Xight-sweats  are  often  of  daily 
occurrence.  The  cough  is  constant,  but  varies  greatly 
from  time  to  time,  and  in  individuals  as  regards  severity 
and  frequency.  It  is  accompanied  by  the  expectoration 
of  a  muco-purulent  or  purulent  sputa.  If  the  cavities 
are  enlarging  by  the  disintegration  of  lung- tissue  elastic 
fibres  can  be  found  in  the  expectorate.  The  appetite  is 
variable,  l)ut  is  usually  diminished  or  very  capricious. 
Pain  in  the  chest  may  be  felt  in  any  stage  of  the  dis- 
ease. Oftenest  it  is  of  pleuritic  origin  ;  more  rarely  it  is 
neuralgic  or  rheumatic. 

Inspection  of  the  bare  chest  demonstrates  the  great 
emaciation  which  has  occurred.  The  lungs  do  not  ex- 
pand equally,  and  respiration  is  much  quickened.  Pal- 
pation reveals  increased  vocal  fremitus  over  areas  of 
consolidation.     Not  unfreqnently  a  bronchial  fremitus 


Pulmonary  Tuhey^culosis.  133 

can  be  felt.  Resonance  is  lessened  when  there  is  con- 
solidation, but  is  t3'mpanitic  or  senii-tympanitic  over 
superfi(nul  cavities.  Over  areas  of  consolidation  the 
respirator}'  sounds  are  broncho-vesicular,  or  bronchial ; 
over  cavities  they  may  be  cavernous  or  metamorphosing  ; 
or,  constant  bul>bling  rales  may  be  heard  at  one  point, 
rales  that  do  not  move  or  disappear  after  a  cough,  or 
with  cliMuges  of  the  patient's  [)osition.  Often,  however, 
we  must  rely  upon  the  discovery  of  elastic  fibres  in  the 
sputa  in  order  to  prove  th.it  excavation  has  begun  or  is 
progressing. 

Toward  the  close  of  life  the  pulse  grows  more  thread- 
like ;  the  skin  becomes  moist  and  gradually'  cold.  Res- 
piration is  very  shallow  and  may  be  labored.  Cyanosis 
is  apparent.  The  mind  may  remain  clear  to  the  last, 
but  oftenest  consciousness  graduall}^  is  lost  as  cyanosis 
deepens.  During  the  last  few  days  of  life,  or  at  least 
during  the  last  few  hours,  coughing  becomes  infrequent 
or  ceases,  or  if  it  occur  is  unaccompanied  by  expecto- 
ration. Mucus  and  oedema  gradually  obstruct  the 
lu'onchi  and  lungs  until  respiration  is  impossible. 

I  have  described  the  stages  of  chronic  tubercular 
phthisis  ns  though  they  followed  each  other  rapidly,  but 
they  ma}'  not  do  so.  Periods  of  quiescence  or  of  par- 
tial recovery  are  the  rule.  The}'  may  occur  between  the 
various  stages,  or  in  their  midst.  For  exjunple,  some 
pulmonary  consolidation  may  be  developed,  nnd  then 
apparent  restoration  to  health  may  occur.  After  months 
or  years  an  extension  of  consolidation  may  take  place, 
or  a  cavity  may  form.  It  is  these  periods  of  quiescence 
that  make  the  disease  so  eminently  chronic.  During 
them  the  physical  signs  of  some  consolidation  or  of  a 
cavity  will  remain  The  tempeature  may  be  normal  in 
range,  but  its  daily  curve  usually  differs  from  a  normal 


134  Disease.':  of  fhe  Lungs. 

one,  in  that  the  maximum  point  occurs  late  in  the  after- 
noon instead  of  early. 

It  is  important  to  know  what  are  symptoms  of  im- 
provement. One  of  tiie  first  tiiat  is  noticeable  is  disnp- 
pearance  of  temperature  or  prolonged  remissions.  The 
pulse  becomes  slower  and  often  fuller.  Flesh  is  gained. 
It  is  true,  that  rarely  flesh  may  be  gained  wiiile  the  fever 
persists.  An  individual's  change  in  weight  is  so  good  n 
criterion  of  the  course  the  disease  is  pursuing  that  it 
should  be  frequently  observed.  A  gain  in  weight  is  sig- 
nificant, at  least,  of  a  diminished  general  tubercular  in- 
toxication. A  sign  of  improvement  still  more  im- 
portant is  an  increase  of  respirator}'  capacity.  It 
means  that  the  lungs  are  filling  more  perfectly,  and, 
nsualh',  that  the  croupous  and  catarrhal  exudates  are 
at  least  in  part  being  absorbed.  This  change  does 
not  occur,  as  a  rule,  except  during  remissions  in  the 
disease.  Changes  in  the  respirator}'  capacit}'  are  best 
measured  b}'  the  spirometer.  When  very  considerable 
increase  takes  place,  measurements  of  the  chest's  girth 
at  the  end  of  deep  inspiration  will  demonstrate  it.  The 
physical  signs  change  if  improvement  occur  in  the  con- 
dition of  the  lungs.  It  must  be  remembered  that  im- 
provement in  a  consumptive's  general  condition  often 
occurs  witlTout  a  diminution  in  the  extent  of  diseased 
tissue  in  the  lung,  and  is  coincident  onl}'  with  a  cessa- 
tion in  the  activity  of  the  disease.  If  areas  of  consoli- 
dation not  only  cease  to  increase,  but  also  contract 
and  become  encapsuled,  dullness-will  diminish,  and  all 
other  physical  signs  of  consolidation  will  be  less  notice- 
able, or  will  disappear.  If  a  cavity  cease  to  grow  or  it 
contracts,  the  signs  of  its  existence  will  be  less  diffuse 
or  evident.  Elastic  fibres  will  disappear  from  the  sputa. 
The  latter  will  become  less  purulent  and  less  abundant. 


Pulmonary  Tuherculoais.  135 

The  tubercle  bacilli  will  dimiDisli  in  number  and  ma}' 
disappear.  Improvement  may  go  so  far  that  a  consump- 
tive may  be  able  to  accomplish  work  e(|ual  to  that  of  a 
man  in  perfect  health,  and  still  a  cure  may  not  be 
effected.  To  accomplish  tlie  latter,  all  tubercular  poison 
that  exists  in  the  lungs  must  be  destroyed,  not  simply 
rendered  dormant  to  be  rekindled  later.  The  cough  is 
one  of  the  last  symptoms  to  leave  a  case  doing  well.  Its 
severity  is  never  a  criterion  of  the  intensity  of  the  dis- 
ease. 

There  are  several  important  complications,  of  more 
or  less  frequent  occurrence.  Indigestion  is  not  uncom- 
mon. It  is  freqnenth'  the  result  of  a  catarrhal  inflam- 
mation of  the  stomach.  A  disinclination  for  food  is 
ver}'  common,  but  more  than  half  the  time  it  does  not 
indicate  indigestion  ;  for  if  food  is  introduced  into  the 
stomnch  it  does  not  ferment  or  cause  distress  ;  and, 
furthermore,  experiments  have  demonstrated  that  the 
stomach  secretes  a  normal  gastric  juice.  Disorders  of 
the  stomach  are  suspected  oftener  than  the}^  occur. 

Diarrhoea  may  occur  at  any  stage  of  the  disease.  It 
commonly  has  two  origins.  It  may  be  due  to  catarrhal 
inflammation  of  the  intestine  or  to  tubercular  nlceration. 
The  latter  is  a  lesion  of  gravity,  while  the  former  rarely 
is,  except  when  the  individual,  for  other  causes,  is  ex- 
tremely weak,  and  cannot  withstand  even  moderate 
additional  exhaustion.  It  is  often  diflflcult  to  diflfer- 
entiate  between  catarrhal  and  tubercular  inflammation 
of  the  intestines.  If  the  tubercle  bacillus  is  discover- 
able in  the  faeces  tubercular  inflammation  may  be  con- 
fidentlv  diagnosed,  for  it  is  very  seldom  that  the  bacilli 
are  swallowed  and  voided  from  the  intestines  unchanged. 
Tubercular  ulceration  rarel}'  occurs  while  the  bowels  re- 
main constipated.     In  some  cases  symptoms  of  sudden 


136  Diseases  of  the  Lungs. 

peritonitis,  i)eri-  or  para-  typhlitis,  intestinal  perfora- 
tion, liaimorrliage,  or  signs  of  internal  bleeding  first 
suggest  tlie  presence  of  latent  ulcers. 

The  larynx  may  also  be  the  seat  of  a  complicating 
tuberculosis.  In  the  earlier  stages  the  laryngoscope 
will  reveal  swelling  of  the  larynx,  especially  pale,  nodu- 
lar swelling.  Later,  ulcers  can  be  seen.  Hoarseness 
and  even  aphonia  are  common.  Sharp,  piercing  pains 
are  usual.  Swallowing  is  often  so  distressing  that  food 
is  refused,  and  all  attempts  at  deglutition  are  avoided. 

Haemorrhages  may  occur  at  an}^  stage  of  the  disease. 
When  slight,  onh'  streaks  of  blood  are  seen  in  the  sputa  ; 
when  moderate,  a  few  mouthfuls  of  bright-red  and  usualh' 
frothy  blo(Hl  well  up  into  the  throat.  In  severe  cases 
large  quantities  will  be  thus  voided  for  hours  or  even 
days  at  a  time.  When  large  amounts  are  raised  vomit- 
ing may  be  provoked,  or  tlie  blood  may  simultaneOusl}' 
flow  from  the  mouth  and  nose.  Haemorrhage  from  the 
lungs  is  accompanied  by  coughing.  Haemoptysis  is  dis- 
tinguished from  hsematemesis  b}' an  accompanj'ing  cough 
with  the  former  and  vomiting  with  the  latter,  by  a 
brighter  redness  of  the  blood  from  the  lungs  and 
blacker  hue  of  that  from  the  stomach,  b}'  the  alkalinitv 
of  the  former  and  aciditj'  of  the  latter,  b}^  its  absence 
from  the  stools  of  the  former  and  presence  in  those  of 
the  latter,  by  tlie  existence  of  preceding  disease  of  the 
lungs  in  one  case  and  of  the  stomach  in  the  other. 
Haemorrhage  from  the  lungs  is  rnre  for  any  other  cause 
tlian  tubercular  disease,  and  is,  therefore,  an  important 
diagnostic  symptom.     It  is  seldom  dangerous  to  life. 

Pleurisy  is  so  constant  in  its  occurrence  that  it  must 
be  regarded  as  part  of  the  disease  rather  than  as  a  com- 
plication. Often  it  is  chronic,  and  produces  so  little 
pain  and  symptoms  so  insignificant  that  it  escapes  atten- 


Pulmonary  Tuberculosis.  13*7 

tion.  In  a  large  number  of  cases  it  causes  character- 
istic pain  and  other  symptoms.  Not  unfrequentl}'  tu- 
berculosis is  the  cause  of  pleurisj^  with  effusion.  In 
the  beginnings  of  phthisis  the  effusion  may  fill  an  entire 
pleural  cavity  ;  in  the  later  stages,  after  adhesions  be- 
tween thei)leural  surfaces  have  become  extensive,  eff'u- 
sioiis  are  usually  circumscribed  or  pocketed.  Pleuritic 
pains  are  often  very  distressing  and  in  many  cases  recur 
frequently.  They  may  be  felt  at  any  time  diiriug  the 
course  of  the  disease. 

Renal  lesions  do  not  often  form  com})lications.  Re- 
nal tuberculosis  maj'  develop.  More  frequently  amyloid 
infiltration  of  the  kidney  occurs.  The  commonest  he- 
patic complications  are  fatty  degeneration  and  amyloid 
infiltration. 

What  is  called  quick  consumption  or  acute  phthisis 
may  vary  greatly  in  its  course  and  mode  of  develop- 
ment, the  common  feature  of  all  cases  being  the  rapidity- 
of  the  course.  In  many  cases  the  symptoms  are  the 
same  as  those  of  chronic  phthisis,  but  no  periods  of 
quiescence  come  in  their  course,  and  consolidation  and 
excavation  develop  in  quick  succession.  In  many  in- 
stances, during  a  few  weeks  preceding  the  actual  out- 
break of  the  disease,  a  slight  cough  and  noticeable  loss 
of  flesh  will  attract  the  patient's  attention.  Suddenly 
a  sharp  pain  will  be  felt  in  the  side.  The  temperature 
will  rise  to  104°  F.,  or  thereabouts,  and  for  a  few  days 
perhaps  })e  continuous,  but  will  soon  grow  irregular  and 
approximate  a  hectic  type.  Emaciation  wall  progress 
rapidly.  The  cough  will  be  hard  and  painful  at  first. 
The  expectorate  may  nt  first  be  mucous,  later  muco- 
purulent, and,  when  excnvation  progresses,  purulent  or 
gangrenous.  Tubercle  bacilli  can  be  found  in  it.  The 
appetite  is  diminished..    The  bowels  may  be  constipated 


138  Diseases  of  the  Lungs. 

or  irregiilur,  but  often,  toward  the  close  of  life,  the}- 
are  loose.  The  pulse  is  soft  from  the  first,  grows  small, 
'and  is  constantly-  quick.  Respiration  at  first  is  painful, 
on  one  side  at  least,  and  therefore  expansion  of  the  chest 
is  lessened,  and  its  movements  are  superficial.  Almost 
from  the  first  large  areas — lobar  ones  often — are  con- 
solidated by  croupous  inflammation  or  b}' a  combination 
of  it  with  catarrhal  inflammation.  Therefore,  percus- 
sion soon  reveals  dullness  over  these  areas  ;  ausculta- 
tion, bronchial  respiration;  and  palpation,  increased  fre- 
mitus. Usually  coarse,  moist  rales  are  abuildant  from 
an  early  date.  The  disease  runs  too  short  a  course  for 
much  contraction  of  the  lungs  to  develop.  In  a  few 
weeks  after  the  consolidation  excavation  begins  and 
progresses  with  rapidity.  It  is  revealed  by  the  usual 
physical  signs,  and  b}-  the  presence  of  bits  of  lung- 
tissue  in  the  sputa.  In  several  instances  I  have  seen 
gangrene  supervene.  The  duration  of  these  cases  varies 
from  six  weeks  to  three  months. 

Diagnosis. — A  diagnosis  is  made  directl}^  by  the  his- 
tory of  loss  of  flesh,  by  the  existence  of  a  small,  soft, 
quick  pulse,  an  irregular  but  persistent  fever,  the  phys- 
ical signs  of  a  circumscribed  bronchitis  or  pneumonia, 
the  existence  of  tubercle  bacilli  in  the  sputa,  and,  in 
the  stage  of  active  excavation,  of  elastic  fibres  in  it. 

It  can  be  differentiated  from  acute  bronchitis  b}^  the 
persistence  of  fever,  by  the  greater  loss  of  flesh,  and  by 
the  limitation  or  concentration  of  the  physical  signs  at 
the  apex  of  one  or  both  lungs.  In  simple  bronchitis 
the  inflammation  is  quite  uniformly  diflTused  in  both 
lungs.  After  consolidation  and  retraction  have  oc- 
curred, it  cannot  be  confounded  with  bronchitis,  although 
it  might  be  with  interstitial  pneumonia  and  peri- 
bronchitis.    The  latter  aflTections  are  not  accompanied 


Pulmonary  Tuberculosis.  139 

by  the  hectic  fever  and  progressive  emaciation  which  are 
inseparable  from  phthisis.  In  the  stage  of  excavation 
elastic  fibres  are  significant,  although  they  maybe  found 
in  the  sputa  that  comes  from  simple  abscess  and  gan- 
grene of  the  lung.  In  the  stage  of  softening  it  can 
hardly  be  confounded  with  an}'  other  disease,  because 
of  the  history  of  its  development,  its  chronicit}^,  the 
chiefly  apical  location  of  its  lesions,  the  simultaneous 
existence  of  areas  of  consolidation,  retraction,  and 
excavation.  The  discovery  of  tubercle  bacilli  iu  the 
sputa  at  any  stage  makes  a  diagnosis  a  positive  oue. 

Causes. — So  generally  is  it  admitted  tiiat  tubercular 
inflammation  is  due  to  the  bacillus  tuberculosis  that  I 
have  uot  discussed  the  history  of  the  growth  of  knowl- 
edo^e  in  reoard  to  it.  Belief  that  this  b.'icillus  is  the 
cause  of  the  disease  is  based  upon  the  facts  that  (1)  it 
is  always  found  associated  with  its  lesions,  and  (2), 
when  isolated  and  inoculated  into  animals,  it  produces 
characteristic  tubercular  lesions.  A  few  cases  of  acci- 
dental inoculatiou  of  man  have  borne  the  same  results. 

It  is  found  that  the  bacillus  does  not  produce  the 
disease  with  equal  readiness  in  all  animals,  and  that  all 
men  are  not  equally  susceptible  to  it.  Therefore,  there 
must  be  other  predisposing  causes  or  susceptible  states 
of  the  system.  A  predisposition  to  the  disease  may  be 
either  inherited  or  acquired.  It  is  very  rare,  if  ever, 
that  the  bacillus  is  transmitted  to  the  child  while  in  the 
uterus ;  but  tuberculous  and  cancerous  or  otherwise 
very  feeble  parents  usually  give  birth  to  children  who 
are  peculiarly  susceptible  to  the  disease.  Many  inf:ints 
are  infected  by  the  milk  of  tuberculous  mothers  or 
nurses,  and  usually  become  scrofulous,  or  develop 
intestinal  tuberculosis. 

There  are  several  factors  by  means  of  which  a  sus- 


140  Diseases  of  the  Lungs. 

ceptibility  may  be  acquired.  Usually  several  of  these 
factors  act  together.  Persons  who  breathe  air  that  is 
confined  in  poorly-ventilated  rooms,  and  especiall}'  air 
that  is  simiiltaneousl}'  breathed  b}^  many  persons,  are 
peculiarly  apt  to  develop  a  susceptibility.  They  are 
liable  to  the  malady  both  because  their  general  vigor 
and  abilit}^  to  withstand  disease  is  lessened  by  breathing 
such  air,  and  because  the  air  is  es[)ecially  apt  to  contain 
the  bacilli. 

Lack  of  exercise  is  a  second  factor  that  aids  in 
developing  a  predisposition.  If  general  exercise  is 
wanting,  vigorous  health  and  powers  of  resistance 
cannot  be  maintained.  If  exercise,  such  as  will  insure 
frequent,  deep  breathing,  is  wanting,  the  lungs  will  be 
imperfectl}'  expanded  and  air  will  remain  in  them  long 
unchanged.  If  the  lungs  are  thus  imperfectlj^  venti- 
Inted,  it  is  possible  for  the  bacilli  to  gain  lodgment  and 
to  remain  long  enough  to  grow.  As  the}'  grow^  with 
l)eculiar  slowness,  good  pulmonnr}-  ventilation  will 
greatl}'^  help  to  prevent  infection. 

Foods  may  be  a  source  of  infection.  Cows'  milk 
and  beef  sometimes  contain  tubercle  bacilli,  and  when 
eaten  ma}'  cause  tuberculosis.  This,  however,  rarely 
occurs,  except  in  infancy,  when  raw,  infected  milk  may 
})e  taken  for  weeks  and  months  consecutively.  Healthy 
digestion  often,  but  not  always,  kills  the  bacilli.  Cook- 
ing always  will.  There  need  be  little  fear  of  tuberculous 
food  if  it  is  not  taken  raw.  A  lack  of  nutritious  food 
will  cause  a  degree  of  general  feebleness  which  makes 
one  little  resistant  to  nn}-  form  of  illness. 

Other  i)uln)()nary  diseases,  especially  chronic  ones, 
predispose  to  tuberculosis  of  tiie  lungs,  by  removing 
the  natural  guards  of  tiie  respirator}'  passages  against 
infection.     Bronchitis  often  destroys  the  ciliated  epithe- 


Pulmonary  Tuhei^culosis.  141 

lium  of  the  bronchi,  whose  function  it  is  to  keep  the 
latter  clean.  Excoriations  or  superficial  ulcerations 
make  it  comparatively  eas}-  for  infectious  germs  to  gain 
access  to  the  deeper  interstitial  tissues,  and  to  lodge  in 
the  air-passages  long  enough  to  multiply.  We  there- 
fore find  pulmonary  tuberculosis  often  following  other 
inflammatory  affections  of  the  lungs. 

Diabetes  is  a  general  disease  which,  with  peculiar 
frequenc}",  is  followed  by  or  associated  with  tuberculosis. 
It  certainl}'  creates  a  susceptibilit}^  to  the  latter  disease. 

Both  sexes  are  aflTected  with  equal  frequenc}^  Pul- 
monar}^  tuberculosis  may  develop  at  any  age,  but  it  is 
least  likely  to  in  the  earliest  and  latest  years  of  life. 
Most  frequently  the  earliest  symptoms  can  be  detected 
in  the  latest  3^ears  of  youth  and  earliest  years  of  adult 
life. 

It  is  a  disease  that  is  ubiquitous.  It  can  be  found 
in  all  climates.  It  is,  however,  not  equnlly  common  in 
all.  In  general  it  maj'  be  said  that  in  the  most  sparsely 
peopled  regions  of  the  world  it  is  most  infrequent.  High 
altitudes  and  higli  latitudes  are  most  exempt  from  it. 
The  coldness  of  such  localities  leads  to  purit}'  of  tlie  air. 
The  rarefaction  of  the  atmosphere  in  high  altitudes  also 
contributes  to  its  purity,  especially  to  its  freedom  from 
dust,  because  the  latter  is  not  easily  suspended  in  thin 
nir.  The  liabits  of  the  inhabitants  of  such  regions 
necessitate  vigorous  exercise  out  of  doors,  and  the 
stimulating  qualities  of  the  dry.  cool  air  incite  them  to 
it.  This  insures  deep  and  freciuent  bieathing  of  pure 
air  and  the  maintenance  of  a  good  circulation.  The 
rarefied  air  of  high  altitudes  necessitates  deep  breathing, 
involuntarily  trains  the  muscles  of  respiration,  and 
develops  voluminous  lungs. 

Pulmonary  tuberculosis  is  also  somewhat  less  fre- 


142  Diseases  of  the  Lungs. 

quent  upon  dry,  well-drained  soils  than  upon  low  and 
poorl3'-drained  ones.  The  disease  is  most  abundant  in 
temperate  and  warm  climates,  where  the  soil  and  air  are 
damp  and  the  temperature  is  changeable. 

Pulmonar}'  tuberculosis  is  a  constant  scourge  and 
is  more  deadly  than  the  epidemic  diseases.  On  an  aver- 
age, 1  in  7  of  all  who  die,  the  world  over,  succumbs  to 
it.  In  certain  localities  the  mortality  is  much  greater, 
and  in  others  less.  In  many,  especially  in  old  prisons, 
from  50  to  70  per  cent,  of  the  deaths  are  from  this 
disease.  Clean,  fresh  air  is  so  important  for  its  preven- 
tion that  good  ventilation  of  rooms  and  good  ventila- 
tion of  the  lungs,  maintained  by  exercise,  have  lowered 
high  mortalities  from  it  in  the  inhabitants  of  prisons, 
barracks,  schools,  and  monasteries. 

Prophylaxis. — Prophylaxis  is  extremel}^  important. 
We  can  hope  that,  by  a  proper  regulation  of  the  life  of 
the  people,  it  ma}^  be  possible  to  greath'  diminish  the 
frequency  of  the  occurrence  of  pulmonarj'  phthisis. 
This  must  be  accomplished  bj-  preventing  infection,  b}^ 
removing  an  inherited  predisposition,  and  by  preventing 
its  acquisition.  Tuberculous  milk,  whether  it  comes 
from  a  mother  or  from  cows,  should  not  be  fed  to 
infants.  Tubei-culous  milk  and  mejit  are  less  apt  to 
infect  adults,  for  they  rarely  take  much  of  either  in  an 
uncooked  state. 

As  infection  takes  place  almost  exclusive^  through 
the  respiratory-  passages  by  means  of  contaminated  air, 
it  is  self-evident  that  pure  air  only  should  be  breathed. 
To  prevent  contamination  the  bacilli  should  be  destroyed 
as  far  as  possible,  and  perfect  ventilation  of  living-rooms 
and  shops  should  be  maintained.  The  nir  is  contam- 
inated by  tuberculnr  matter  only  Mhen  the  latter  is 
dried  and  forms  a  part  of  the  atmosphere's  dust.     Such 


Pulmonary  Tuberculosis.  143 

dust  is  almost  exclusively  formed  by  the  drying  of 
sputa.  Wlien  it  is  remembered  that  sputa  is  cast  upon 
the  floor  of  buildings,  upon  the  ground,  and  upon  hand- 
kerchiefs or  other  articles  of  dress,  and  permitted  to  dry 
and  be  scattered  by  air-currents,  the  abundance  of  the 
contaminating  material  becomes  evident.  For  the  safety 
of  others,  tuberculous  patients  should  be  instructed  to 
always  expectorate  into  vessels  filled  with  water,  or 
upon  handkerchiefs  or  other  articles  that  can  be  boiled 
or  burnt  before  they  (\vy.  Cuspidors  should  not  be 
emptied  upon  the  ground,  but  into  sewers  or  upon  a 
fire.     The}^  should  often  be  thoroughly  scalded. 

If  sleeping-rooms,  living-rooms,  factories,  oflflces,  and 
halls,  where  much  of  our  life  is  spent,  are  well  ventilated, 
the  air  will  be  constantly  diluted  and  purified,  so  that 
the  chances  of  infection  will  be  greatl}^  lessened.  The 
fact  that  those  whose  occupations  or  modes  of  life 
necessitate  their  breathing  a  close  and  confined  air,  and 
especially  one  that  many  are  simultaneously  breathing, 
are  more  subject  to  the  disease  than  others,  establishes 
the  need  of  fresh  air  for  healthful  living.  Some  3^ears 
ago  it  was  found  that,  among  certain  English  soldiers, 
the  mortality  from  consumption  exceeded  very  greatlj' 
that  among  the  towns-people  about  them.  The  old  and 
poorl^'-ventilated  barracks  -that  they  were  then  using 
were  torn  down  and  replaced  b}"  new  ones,  especiallj^ 
constructed  to  maintain  ventilation  as  perfect  as  pos- 
sible. The  result  was,  that  the  mortalit}-  fell  to  as  low 
a  point  as  in  the  healthiest  districts  of  England.  A  life 
out-of-doors — if  possible,  in  the  countrj- — should  be  led 
by  those  predisposed  to  the  disease. 

The  bad  influence  of  a  sedentarj^  life  upon  those  pre- 
disposed, and  its  influence  in  developing  a  predispo- 
sition, emphasizes  the  need  of  exercise  as  a  means  of 


144  Diseases  of  the  Lungs. 

propli3'laxis.  Exercise  should  be  general  to  maintain  a 
good  degree  of  nutrition  and  a  vigorous  circulation. 
The}'  must,  also,  often  be  especially  adapted  to  develop 
the  lungs  and  to  increase  tlie  forcefulness  of  respiration. 
In  those  whose  build  predisposes  them  to  consumption 
the  lungs  are  unusuall}-  small  in  vertical  diameter,  but 
very  long,  and  the  heart  is  small.  General  exercise  will 
strengthen  and  enlarge  the  heart.  Pulmonar}^  exercise 
— that  is,  voluntar}^  deep,  full  breathing — will  enlarge 
the  lungs,  strengthen  the  respirator}'  muscles,  and 
create  a  habit  of  deep  breathing.  Life  at  high  altitudes, 
hill-climbing,  and  running  especially  lead  to  involuntary 
deep  breathing.  In  young  people  the  chest  is  mobile, 
and  can  be  shaped  and  enlarged  bj'  persevering  exercise. 
It  is  often  necessary  to  correct  other  muscular  weak- 
nesses which  produce  deformities  that  hinder  good 
respiration :  such  are  round  shoulders  and  stooped  neck. 
They  are  due  to  weak  shoulder-  and  back-  muscles.  For 
children  and  youth  who  are  physicall}-  deficient  special 
physical  training  is  needful. 

Dail}^  baths  or  douches,  and  thorougli  rubbing  after 
them,  are  useful  in  training  the  peripheral  vessels  to 
dilate  promptlj^  and  restore  warmth  to  the  skin  when  it 
is  suddenly  chilled.  If  this  habit  can  be  acquired  by 
the  vessels  the  evil  etfects  of  sudden  and  violent  atmos- 
pheric changes  will  be  lessened. 

The  body  should  be  constnntly  covered  by  woolen 
garments.  They  may  be  light  or  heavy,  according  to 
the  season,  but  in  changeable  climates  they  should  be 
worn  throughout  the  year.  It  is  best,  also,  that  woolen 
night-garments  should  be  worn.  The  advantage  of 
woolen  clothes  is,  that  they  maintain  within  themselves 
an  atmosphere  that  is  slowly  influenced  by  external 
changes.     They  are  porous,  and  do  not  keep  upon  the 


Pulmonary  Tuberculosis.  145 

skin  exhalations  wiiich  sliould  be  carried  off  in  order  to 
maintain  cleanliness.  Certainly,  colds  are  less  fre- 
quentl}'  taken  or  aggravated  b}^  those  who  exercise  such 
care  in  dressing. 

The  climate  best  adapted  to  those  disposed  to  the 
disease  will  be  indicated  when  the  climates  which  are 
most  suitable  tor  the  different  stages  and  varieties  of 
consumi)tion  nre  descrilted.  For  tiiose  especial!}'  sus- 
ceptible out-door  em[)h)yments  shoukl,  b}-  all  means,  be 
preferred.  Close  confinement  to  a  desk  or  at  trades, 
such  as  sewing,  tailoring,  and  shoe-making,  should  espe- 
cially be  avoided  ;  particularly  should  such  individuals 
not  work  in  poorly- ventilated  rooms. 

If  the  tonsils  of  a  child  are  chronicall}'  enlarged 
and,  by  their  mechanical  interference  with  respiration, 
prevent  the  proper  development  of  the  chest,  they 
should  be  removed.  Respiratory  affections,  especially 
such  as  subacute  or  clironic  bronciiitis,  should  be  cared 
for  as  quickly  as  possible,  for  the}'  also  make  the  indi- 
vidual affected  more  susceptible  to  infection. 

Treatment — Hygiene. — We  know  of  no  specific  for 
tuberculosis.  Medicinal  treatment  is  therefore  symp- 
tomatic. Hygienic  treatment  is  all  important.  Hygi- 
enic measures,  as  well  as  medicinal  treatment,  must  be 
adapted  to  individual  cases.  Pure  air  is  as  essential  to 
the  consumptive  as  to  those  predisposed  to  the  disease. 
The  purest  air  is  found  in  mid -ocean  and  upon  moun- 
tain-tops. It  is  better  in  the  country  than  in  the  city. 
At  high  altitudes — that  is,  at  elevations  of  more  than 
five  thousand  feet — advantage  is  derived  not  only  from 
the  purity  of  the  air,  but  from  its  rarefaction  and  con- 
sequent influence  upon  the  depth  and  frequency  of 
respiration.  High  altitudes  are  especially  indicated  for 
young  people  who  are   predisposed  to  the  disease,  or 

7    G 


146  Diseases  of  the  Lungs. 

have  it  in  its  incipienc}',  provided  tliey  do  not  have 
fever.  It  is  indicated  for  fibroid  phtliisis,  especially  if 
it  occur  in  young  persons.  It  is  also  indicated  for 
tliose  suffering  ,  from  any  A^ariety  of  chronic  phthisis 
during  a  period  of  quiescence.  But  it  is  not  so  uni- 
forml}"  beneficial  in  those  who  are  past  middle  life  or 
ver}^  feeble.  The  rarefaction  of  the  air  causes  involun- 
tary, deep,  and,  at  first,  frequent  respiration.  Little  by 
little  the  lungs  expand,  so  that  their  capacity  is  in- 
creased. As  this  change  takes  place  the  breathing 
becomes  slow,  but  remains  unusually  deep.  The  deep 
and  strong  respiratory  movements  that  are  thus  con- 
stantly necessitated  enforce  a  better  ventilation  of  the 
lungs,  a  better  oxygenation  of  the  blood,  and,  therefore, 
more  active  tissue-change  throughout  the  bod}',  and  a 
strengthening  of  tlie  respirator}-  muscles.  The  increased 
capacit}'  of  the  lungs  is  brought  about  b}^  distension  of 
the  air-cells  which,  in  lower  altitudes,  are  only  partly 
expanded  and  little  used,  and  often  by  rendering  other 
portions  emphysematous.  This  helps  to  prevent  infec- 
tion by  mruntaining  good  ventilation  of  the  lungs. 
Emphysema  is  usuall}^  produced  about  areas  of  consoli- 
dation. The  stretching  of  the  lung-tissue  here  and 
consequent  stretching  and  narrowing  of  the  capillaries 
prevent  congestion.  The  dryness  which  is  character- 
istic of  liigh-altitude  atmospheres  causes  the  exhalation 
of  unusually  large  quantities  of  water.  This  aids  in 
bringing  about  an  absorption  of  inflammatory  exudates. 
The  breathing  of  pure  air  lessens  the  tendency  to  infec- 
tion by  p3^ogenic  organisms,  and  the  liabilit}^  to  form 
abscesses.  Dry,  clean,  cool  mountain-air  is  peculiarly 
invigorating  to  the  nervous  system.  It  often  stimulates 
the  ambitionless  and  letliargic  to  take  the  all-neede(i 
gxercise.     It  gives  greater  buoyancy  of  spirits. 


Pulmonary  Tuberculosis.  147 

High  altitudes  are  contra-indicated  in  acute  catarrhal 
cases,  or  in  other  forms  in  which  there  is  an  acute  exacer- 
bation. Fever  is  a  contra-indication,  since  it  is  usually 
aggravated  by  high  altitudes.  Great  debility  is  also  a 
contra-indication.  If  the  lungs  are  so  extensively  in- 
volved in  consolidation  or  excavation  that  respiration 
cannot  be  well  maintained  in  rarefied  airs,  the  high  alti- 
tudes are  likewise  contra-indicated.  A  very  nervous 
temperament  contra-indicates  them  ;  for  the  stimulating 
air  may  cause  sleeplessness,  extreme  nervousness,  and 
even  muscular  pains. 

Many  places  in  the  Rocky  Mountains  are  high-alti- 
tude climates  par  excellence.  In  this  vast  region  em- 
ployment can  be  found  by  those  who  can  take  it;  and 
ver3^  excellent  locations  for  permanent  residence  exist 
there.  Of  health  resorts  Colorado  Springs  and  Mauitou 
are  the  most  famous.  The  Alps  in  Switzerland  are  also 
famous  for  the  cure  of  consumption,  but  they  are  not 
as  good  as  the  Rockies,  since  permanent  residence  in 
high  altitudes  cannot  so  well  be  maintained  there,  for  in 
the  spring,  when  the  snow  melts,  the  air  becomes  damp, 
and  exercise  is  limited  bj'  the  wet  and  slush.  l\\  the 
Rockies  snow  lies  on  the  ground  only  a  short  time  and 
disappears  with  rapidity  at  most  of  its  health  resorts. 
High-altitude  residences  are  few  in  the  Apalachian 
Mountains,  and  when  they  exist  they  are  on  mountain- 
peaks  that  are  frequently  cloud-capped,  enveloped  in 
mist,  and  exposed  to  harsh  winds ;  but  residences  at 
moderate  altitudes  of  two  thousand  or  three  thousand 
feet  are  numerous.  The3"  afford  climates  that  are  stim- 
ulating and  air  that  is  pure,  while,  for  those  who  can 
take  exercise,  the  hill-climl)ing  will  accomplish  nearly 
as  much  toward  expanding  the  lungs  and  dilating  the 
c^iest  as  the  rarefied   air  of  high   altitudes.     They  are 


148  Diseases  of  the  Lungs. 

better  suited,  too,  for  those  whose  lungs  are  extensively- 
crippled  and  who  are  greatl}'  enfeebled. 

Sea-air,  which  can  onl^'  be  had  to  the  fullest  advan- 
tno-e  at  sea,  on  a  vessel,  is  especiallj'  suited  to  the  same 
classes  of  cases  as  high  altitudes,  and  also  to  persons 
past  middle  life  and  to  those  greatly  weakened.  It  is 
characterized  bv  purit}' ;  therefore,  suppuration  from 
superimposed  infection  is  not  likely  to  occur.  It  is 
invigorating  to  digestion  and  nutrition,  and  its  moisture 
and  equability  make  it  palliative  to  dr}',  harsh  cough- 
ing. Involuntary  expansion  of  the  lungs,  enlargement 
of  the  chest,  and  prompt  absorption  of  inflammatory 
exudates  must  not  be  expected.  Pulmonary  exercises, 
when  indicated,  must  be  voluntarih'  taken.  The  great- 
est benefit  has  been  derived  from  high-altitude  and  sea 
airs;  but,  if  the  best  results  are  expected,  cases  must 
be  carefully  selected  for  each.  Sea-climates,  because 
of  their  sedative  influence,  are  indicated  for  the  ver}' 
nervous,  who  are  too  greatl}'  stimulated  by  drj',  high- 
altitude  air. 

Long  sea-vo3'ages,  as  well  as  prolonged  residence  at 
high  altitudes,  is  essential  to  produce  the  desired  effects. 
At  least  six  months,  and,  better  still,  a  year  or  more, 
should  be  spent  in  these  climates.  A  sea-vo3'age  is  con- 
tra-indicated for  those  who  are  ver}'  weak  or  in  danger 
of  rapid  failure,  since  they  cannot  turn  back  when  started. 
It  is  contra-indicated  for  those  subject  to  prolonged  sea- 
sickness. A  time  of  year  and  a  direction  should  be 
chosen  tlint  will  promise  good  weather.  Three  succes- 
sive summers  can  be  had  by  starting  from  the  northern 
temperate  zone  nnd  sailing  across  the  Equator  to  the 
southern  })art  of  America  or  Africa  or  Australia,  so 
that  the  winter  will  be  pnssed  in  southern  seas,  and  a 
return  voynge  made  so  that  home  is  reached  the  follow- 


Pulmonary  Tuberculosis.  149 

ing  spring  or  summer.  Boats  should  be  selected  that 
are  not  overcrowded  with  passengers  and  that  are  well 
provisioned.  Good  and  varied  food  is  essential  for  an 
invalid.  A  voyage  in  a  sailing-vessel  is  the  best  for  an 
invalid,  for  such  boats  go  more  leisurely  and  are  less 
crowded  than  steamers. 

A  modified  sea-air  can.  be  had  ui)on  many  islands 
and  coasts,  which  is  often  very  beneficial.  But  it  is 
neither  so  pure  nor  so  constanth"  invigorating,  because 
more  changeable.  Islands  often  resorted  to  are  the 
Bermudas  and  the  West  Indies.  Shore  resorts  are 
numerous.  Those  of  California  .and  Florida  are  pecu- 
liarl}^  favorable  to  many  cases  of  consumption. 

It  is  desirable  to  remove  mau}^  consumptives  who, 
although  in  the  early  stages  of  the  disease,  are  feverish 
and  ill  adapted  to  the  climates  already  mentioned  from 
the  changeable  and  inclement  weather  of  our  northern 
cities.  Those  who  are  suffering  in  the  advanced  stage 
of  the  disease,  if  it  is  not  making  rapid  progress,  are 
also  benefited  hy  escaping  winter  and  spring  weather  at 
the  North.  For  persons  who  are  naturallj-  lethargic 
and  need  a  stimulating  climate,  the  dr3^,  mild,  and 
equable  air  of  Southern  California  is  peculiarl}^  favor- 
able. Its  distance  often  makes  it  inaccessible.  West- 
ern and  Southern  Texas  afford  an  excellent  winter  and 
spring  climate  for  those  who  need  a  moderatel}'  dr3^  and 
warm  air,  and,  therefore,  one  moderately  stimulating 
and  genial.  Those  who,  because  of  the  nature  of  their 
case,  cannot  make  their  home  either  at  high  altitudes  or 
on  or  b}^  the  sea,  are  often  most  benefited  by  transitor}' 
residence  in  southern  States  during  the  winter  and  earl}^ 
spring,  and  amid  the  pine- forests  and  moderate  eleva- 
tions of  Virginia,  Georgia,  or  New  York  in  summer 
and    autumn.        Often    those    who    cannot    safely    take 


150  Dif^eases  of  the  Lungs. 

advantage  of  a  high-altitude  climate,  because  of  fever 
and  the  acuteness  of  their  trouble,  though  in  the  first 
stage  of  the  disease,  can  spend  the  winter  with  benefit 
near  San  Antonio,  Texas.  There  the}'  can  live  almost 
constant!}'  out  of  doors  and  take  the  needed  exercise, 
while  the  change  will  invigorate  the  appetite  and  usu- 
ally cause  a  general  improvement.  Often  their  fever  is 
gone  before  spring,  and  the}'  can  go  with  safety  and  the 
greatest  advantage  for  a  sojourn  of  a  year  or  more  to 
Colorado  or  Xew  Mexico,  where  the  mechanical  effects 
of  a  rarefied  air  ma}'  be  obtained. 

Localities  should  always  be  chosen  where  there  are 
few  cloudy  days,  and  where  violent  atmospheric  changes 
are  rare. 

Often  pure  air  must  not  only  be  sought  by  changes  of 
climate,  but  it  must  be  insured  in  the  homes  or  places 
of  business  of  consumptives.  As  little  time  should  be 
spent  in-doors  as  possible  by  those  able  to  be  out.  Sleep- 
ing-rooms should  be  most  thoroughly  ventilated.  T'heir 
windows  should  be  kept  open  by  day,  and  if  it  is  neces- 
sary they  may  be  moderately  warmed  before  bed-time. 
Warm  clothing  and  bedding  should  be  at  hand,  but  the 
temperature  of  the  air  need  not  be  high.  For  those 
who  are  able  to  be  about  the  house  and  out  by  day,  it 
need  not  in  winter  l)e  more  than  45°  or  50°  F.  if  the 
air  is  dry,  but  must  be  much  warmer  if  it  is  damp.  For 
those  who  are  quite  weak  it  is  best  that  the  temperature 
of  the  room  be  kept  uniform  and  at  about  68°  or  70°  F. 
For  tliose  wlio  cannot  leave  the  house,  but  can  leave 
their  beds,  it  is  best  that  two  rooms  be  at  their  disposal, 
one  to  be  used  by  night  and  the  other  by  day.  The 
one  occupied  by  day  should  be  sunny  and  cheerful ;"  its 
windows  should  be  opened  wide  by  night,  as  the  others 
are  by  day.     At  all  times  there  should  be  permitted  an 


Pulmonary  Tuberculosis.  151 

egress  of  air  that  a  constant  change  and  freshness  of  the 
atmosphere  maybe  maintained. 

Suitably  regulated  exercise  is  quite  as  essential  for 
the  consumptive  as  for  those  predisposed  to  the  disease. 
Exercise  should  be  regularly  taken,  but  should  never 
be  exhausting.  B}^  those  who  are  feeble  very  little 
should  be  taken  at  a  time,  but  in  varied  forms  it  may 
be  taken  often  through  the  day.  Short  walks  and  rides 
are  all  the}'  can  bear.  By  those  more  vigorous  and 
without  fever  field  sports  and  games  may  be  resorted  to. 
These  general  exercises  help  to  maintain  muscular  tone 
and  vigor,  and  therefore  a  more  perfect  Ijnnph  circula- 
tion. The  latter  helps  to  eliminate  much  that  might  be 
detrimental  if  it  accumulated  in  the  system.  This  is 
probably  the  reason  for  the  frequently-observed  fact 
that,  if  accustomed  exercise  is  not  taken,  night-sweats 
return  and  the  appetite  is  lost.  For  those  in  the  first 
half  of  life,  and  especially  for  those  with  fibroid  phthisis, 
respiratory  g3'mnastics  are  especially  useful.  These 
consist  in  enforced  deep  breathing.  With  the  head  erect 
and  the  shoulders  back,  as  deep  a  breath  should  be 
taken  as  slowly-  as  possible  every  two  minutes  while  one 
is  walking,  and  once  in  from  half  an  hour  to  an  hour 
while  sitting  in-doors.  By  this  means  the  lungs  are 
kept  well  expanded  and  the  air  in  them  most  perfectly 
changed.  The  respirntor}-  muscles  are  strengthened 
and  trained  to  involuntnrily  maintain  deep  breathing. 
The  chest  can  gradually  be  thus  enlarged  quite  as  much 
as  by  higli-altitude  life,  provided  onl}'  one  will  be  suf- 
ficiently persevering.  Another  excellent  but  less-fre- 
quentl}^  available  means  of  maintaining  respiratory 
gymnastics  is  by  the  alternate  inhalation  of  com- 
pressed air  and  exhalation  into  rarefied  air,  such  as 
can  be  aff'orded  by  the  pneumatic  cabinet  and  similar 


152  Diseases  of  the  Lung }:. 

contrivances.  In  this  way  the  good  eti'ects  of  enforced 
deep  breathing  can  be  had,  and  the  lungs  can  usually  be 
more  rapidly  enlarged.  Respiratory  gymnastics,  as 
well  as  general  muscular  exercises,  must  be  gentle  in 
the  extreme  when  debility  is  great,  or  fever  is  continu- 
oush'  liigli?  or  cavities  are  large. 

Hours  for  rest  and  sleep  should  be  regularly  pro- 
vided. Many  consumptives  carr3'  on  business  and  give 
themselves  insufficient  rest.  The  clothing  of  the  con- 
sumptive should  be  light,  but  warm.  Too  much  cloth- 
ing is  frequentl}^  worn.  It  is  burdensome,  restricts  the 
respiratory  movements,  and  is  not  cleanl}'.  Impervious 
garments,  such  as  are  made  of  leather,  are  not  whole- 
some, for  they  make  it  impossible  to  dissipate  the  exha- 
lations from  the  skin.  Mufflers  should  not  be  worn  over 
the  mouth  or  nose,  unless  a  high  wind  must  be  faced  or 
a  cold  air  excites  a  cough.  In  the  latter  case,  they  ma}" 
be  worn  for  a  few  minutes  wdien  the  cold  air  is  first 
struck,  and  until  a  tolerance  of  it  is  obtained. 

For  consumptives  occupations  should  not  be  seden- 
tar3'  or  necessitate  confinement  in-doors,  nor  should 
they  cause  mental  strain  or  worr^'.  The  diet  should  be 
varied,  but  simple.  As  appetite  is  often  poor,  it  should 
be  tempted  by  a  variety  of  food.  If  structural  disease  of 
the  stomach  exist,  it  may  make  necessary  a  still  greater 
modification  of  the  diet.  It  is  usuallj^  necessary  to  crowd 
food  upon  consumptives,  because  of  the  lack  of  incli- 
nation for  it.  It  is  well  to  prescribe,  in  addition  to  such 
food  as  may  be  chosen  at  meal-times,  a  part  or  a  full 
glass  of  good  milk  between  meals  and  at  bed-time.  Milk 
is  especially  wholesome  for  those  who  like  it.  Butter, 
cream,  and  oils  are  also  good,  if  easily  digested.  The 
fat-producers  are  the  ingredients  of  diet  that  are  espe- 
cially needed  by  consumptives.     Codliver-oil  is  peculi- 


Pulmonary  Tuberculosis.  163 

arly  good,  for  it  is  easily  digested.  If  it  is  taken, 
cream  and  otlier  oils  should  not  be  too  much  urged 
upon  a  patient,  lest  his  fat-digesting  powers  be  over- 
tasked. If  indigestion  exist  oils  cannot  be  taken. 
When  they  can  they  help  rapidly  to  increase  flesh,  and 
with  its  increase  otlier  symptoms  are  ameliorated.  The 
best  preparations  of  codliver-oil  are  the  clear,  light- 
colored  ones.  The}'  should  be  given  to  adults  in  as 
large  doses  as  can  be  well  digested.  It  is  best  to  begin 
with  a  teaspoonful  or  less,  and  to  graduall}^  increase  the 
dose.  It  is  also  best  taken  after  eating.  The  taste  maj^ 
be  made  less  objectionable  if  a  little  salt  is  taken  before 
or  after  it,  or  if  a  bitter  like  gentian  is  added  to  it.  The 
various  emulsions  are  palatable,  and  by  many  readil}^ 
taken.  It  is  easy  to  administer  tiie  oil  in  elastic  cap- 
sules containing  from  fifteen  drops  to  a  teaspoonful.  If 
the  taste  of  codliver-oil  constantly  return  to  a  patient's 
mouth,  or  if  it  lessen  the  appetite  for  other  wholesome 
food,  it  is  not  beneficial,  and  either  the  quantity  taken 
must  be  lessened  or  it  must  be  discontinued. 

Malt-extracts  are  concentrated  solutions  of  grape- 
sugar,  with  more  or  less  of  a  diastatic  ferment  added. 
They  have  been  recommended  as  a  substitute  for  cod- 
liver-oil. This  they  are  not.  But  they  are  good  fat- 
producing  foods,  and  as  such  ma}^  be  used. 

Forced  feeding  b}'  a  stomach-tube  has  been  tried  in 
this  disease  where  there  was  great  disinclination  for 
food.  It  has  been  found  that  usually  there  is  no  dis- 
order of  digestion.  Such  feeding  generall}^  causes  an 
increase  of  flesh  and  strength.  It,  however,  does  not 
occur  if  the  destruction  of  the  lungs  is  extensive,  and 
if  weakness  is  consequently'  very  great. 

Treatment^  Medicinal. — Medicinal  trentnient  must  be 
palliative  and  sj-mptomatic.     The  cough  of  tubercular 


154  Diseases  of  the  Lungs. 

phthisis  is  a  chronic  one.  It  ma}'  be  influenced,  as  are 
coughs  from  other  causes,  b}'  expectorants  and  ano- 
dynes; but  as  these  remedies  often  nauseate,  and  usuall}- 
diminish  the  appetite,  the}'  must  be  used  with  discretion. 
As  a  general  rule,  it  may  be  said  that  the}'  must  not  be 
used  if  tbey  can  be  avoided.  If  coughing  is  severe  and 
the  expectorate  is  tight  because  of  a  fresh  cold,  the 
formula  given  on  page  46,  containing  ammonium  muriate, 
will  be  found  serviceable.  But  such  expectorant  mix- 
tures cannot  be  long  used  judiciously.  In  most  cases 
an  anodyne  can  be  advantageously  given  at  night  to 
lessen  the  cough  and  insure  sleep.  The  best  anodynes 
are  codeia,  morphia,  and  chloral.  The  first  of  these  is 
usually  sufficient,  and  is  the  least  objectionable.  When 
the  stoniach  is  irritable,  I  have  found  a  mixture  of 


Acidi  carbolici,     . 

. 

grm.        0.5(1fTtvij); 

Antipyrin,     . 

grms.    10.0  (3iiss)  ; 

Tinct.  gelsemii,     . 

"        15.0  (5iv)  ; 

Glycerinse,     . 

. 

15.0  (5iv)  ; 

Tinct.  opii  camph., 

"        30.0  (Ij); 

Aquae,    . 

q.  s.  ad 

'•      120.0  (5iv)  ; 

to  be  serviceable.  It  allays  the  irritability  of  the  stom- 
ach, and  often  lessens  the  cough  in  a  surprising  way. 
Teaspoon ful  doses  may  be  given  from  every  three  to  six 
hours.  When  the  cough  constantly  needs  mitigating, 
small  doses  of  codeia  may  be  given  every  three  or  four 
hours  without  disturbing  the  stomach,  and  with  benefit. 
To  loosen  the  expectorate  when  it  is  scant  and  tiglit 
the  expectorants  must  be  employed.  If  expectoration 
is  abundant  it  can  be  lessened  by  terebinthines.  Its 
purulent  character  may  also  be  lessened  by  the  same 
remedies.  Beech-wood  creasote  has  been  lauded  as 
especially  curative  for  tubercular  lesions  of  the  lungs. 
I  cannot  think  that,  in  therapeutic  doses,  it  exerts  a 


PuJmonari/  Tuberculosis.  155 

very  powerful  influence  upon  the  bacilli  in  the  Kings,  for 
T  have  never  seen  the  number  of  bacilli  in  the  sputa 
lessened  by  it.  It  is  certainl}'  beneficial  in  rendering 
the  sputa  less  purulent  and  less  abundant.  It  does  not, 
at  the  same  time,  make  the  sputa  adhesive  and  difficult 
to  raise,  as  does  turpentine  and  its  congeners.  Creasote 
may  be  given  in  minim  doses,  and  gradually  increased 
to  four  or  five  times  that  amount,  and  the  doses  may  be 
repeated  every  three  to  six  hours.  It  is  most  agreeably 
administered  in  capsules,  with  gentian  or  pepsin  or  some 
other  vehicle.  A  few  times  I  have  known  it,  in  the 
larger  doses,  to  cause  some  gastric  burning  and  dis- 
tress. More  rarel}',  I  have  found  the  urine  darkened, 
and  exhaling  the  characteristic  odor  of  the  drug.  In 
order  to  get  most  fully  the  best  effects  of  creasote  it 
must  be  given  for  weeks  at  a  time.  I  have  more  fre- 
quently seen  good  results  follow  the  persistent  use  of 
creasote  than  of  any  other  drug.  This  good  effect,  I 
believe,  is  chiefly  due  to  a  diminution  of  the  activity  of 
suppuration. 

When  the  larynx  and  trachea  are  much  inflamed  an 
inhalation  of  hot-water  vapor,  which  has  been  impreg- 
nated with  carl)olic  acid,  or  creasote,  or  turpentine,  or 
pine-oil  and  paregoric,  gives  much  comfort;  it  lessens 
the  cough  and  the  tracheal  and  lar3'ngeal  soreness.  An 
inhalation  of  this  kind  can  be  best  obtained  from  a  flask 
partl}^  filled  with  the  medicated  hot  water  and  fitted 
with  a  cork,  through  which  one  glass  tube  passes  to  the 
bottom  of  the  liquid  and  a  second,  shaped  for  a  mouth- 
piece, into  the  vapor  that  fills  the  upper  part  of  the 
flask.  When  inhalations  are  made  the  air  is  drawn  in 
bubbles  through  the  water,  and  is  thus  laden  with 
moisture  and  is  medicated.  The  inhaler  should  be  used 
often    if  the    inflammation    i:^    sharpl}^    acute.       Steam- 


156  Diseases  of  the  Lungs. 

atomizers  may  l>e  employed  instead  of  the  inhaler,  but 
in  my  hands  have  seemed  less  efficient. 

Codliver-oil  and  malt-extract,  though  more  properly 
foods,  often  lessen  cough,  and  ma}'  be  used,  at  least,  as 
adjuvants.  Troublesome  coughing  can  often  be  pre- 
vented by  careful  management.  Many  patients  are 
most  troubled  by  prolonged  coughing  at  night  when 
the}'  retire  and  on  awaking  in  the  morning.  The  night- 
cough  is  due  partly  to  the  irritability  of  the  nervous 
system  from  weariness,  but  more  to  a  sudden  change  of 
position,  and  often  of  rooms  and  of  clothing.  The 
physical  labor  of  disrobing  and  the  stooping  and  bend- 
ing which  it  necessitates  are  sufficient  to  provoke  a  spell 
of  coughing,  as  can  often  be  proven  b}'  having  a  patient 
assume  the  same  posture  and  make  the  same  movements 
at  other  times  in  the  da}'.  If  a  patient  who  is  troubled 
with  evening  cough  must  climb  stairs  to  a  sleeping- 
room  this  should  be  done  with  great  slowness,  and  a 
rest  of  fifteen  to  thirty  minutes  should  be  taken  before 
clothing  is  removed.  The  room  in  which  the  patient 
undresses  should  be  of  the  same  tempei'ature  as  tiiat 
just  left.  One  garment  should  be  removed  after  another, 
slowly,  and  with  frequent  pauses  for  rest.  It  is  best, 
usually,  that  cheerful  conversation  should  be  kept  up, 
and  the  mind  diverted  from  the  expected  siege  of 
coughing.  In  many  cases  an  attendant  should  help  to 
remove  the  clothing,  so  that  as  little  effort  will  be 
required  of  the  patient  as  possible.  The  night-clothing 
should  be  warmed,  so  that  it  will  not  chill  or  shock  the 
skin.  In  the  process  of  uncovering  the  body,  as  little 
of  it  should  be  exposed  to  the  air  at  one  time  as  possible. 
The  bed  should  be  warmed.  Often  conohino-  can  also 
be  averted  by  not  at  once  reclining  in  bed.  The  patient 
may  at  first  sit  in  bed  or  lean  against  pillows,  and  then 


Pulmonary  Tuberculosis.  15t 

very  gradually  slip  down  into  the  bed  and  assume  a 
recumbent  posture.  An  hour  or  more  should  be  occu- 
pied in  leisurely  getting  to  bed.  The  patient  should, 
therefore,  begin  earl3^  Yery  frequently,  if  those  who 
retire  at  eight  with  a  severe  cougiiing  spell  will  begin  at 
five  or  half-past,  and  get  finall}'  settled  b^-  half-past  six, 
they  will  avoid  it.  It  is  a  mistake  for  consumptives  to 
sit  up  late  or  to  become  too  wearied.  The  morning 
cough  is  oftener  difficult  to  stop,  for  it  is  usually  caused 
by  an  accumulation  of  secretions  in  the  air-passages  or 
in  cavities  during  sleep.  If  coughing  occur  occasion- 
ally during  the  night,  but  does  not  prevent  the  patient 
from  falling  asleep  quickly  again,  it  need  not  be  checked, 
for  it  often  prevents  a  wearisome  and  distressing  spell 
of  coughing  in  the  morning.  The  morning  cough  can 
often  be  mitigated  by  taking  a  warm,  nourishing  drink 
on  first  awaking.  A  cup  of  warm  cocoa  is  particularly^ 
grateful  at  this  time.  When  coughing  begins  the 
patient  should  not  sit  up  or  get  up,  but  should  keep  as 
quiet  as  possible.  In  this  way  coughing  can  be  pre- 
vented from  recurring  with  frequency.  After  the  largest 
part  of  what  is  usually  expectoi-ated  in  the  morning  is 
raised  the  patient  may  begin  to  dress,  but  it  should  be 
done  slowly,  in  a  room  whose  atmosphere  is  genial.  If 
the  patient  is  feeble  the  hot,  nourishing  drink  that  has 
been  recommended  will  be  found  especiall}'  beneficial  if 
taken  an  hour  or  two,  or  even  longer,  before  breakfast- 
time.  Often,  wdien  the  coughing  spell  begins  at  four  or 
five  in  the  morning,  it  will  be  mitigated  by  it,  and  an 
additional  sleep  will  be  obtained. 

Anorexia  is  a  very  common  and  ver3'  troublesome 
S3aiiptom.  A  change  of  air  nnd  scene  are  often  imme- 
diately beneficial.  As  the  maintenance  of  strength  bj' 
food  is  all-important,  to  counteract  a  disinclination  for 


158  Diseases  of  the  Lungs. 

it  becomes  a  necessity.  By  varying  the  diet,  and  by 
having  all  of  its  ingredients  appetizingl3'  prepared,  the 
object  may  be  accomplished.  Oftener  it  is  necessary  to 
administer  food  in  prescribed  amounts  and  with  the 
regularity  of  medicine.  Milk,  or  some  of  its  prepara- 
tions, like  kumyss,can  thus  be  best  given.  It  will  often 
be  more  persistently  taken  if  it  is  medicated.  A  bitter 
tonic  may  be  mixed  with  it.  A  few  years  ago  a  decoc- 
tion of  mullein-leaves  in  milk  was  commended  as  one 
of  the  innumerable  consumptive  cures.  The  gain  in 
weight  and  general  improvement  which  followed  its 
administration  came  from  the  amount  of  food  that  was 
thus  forced  upon  the  patient  rather  than  from  the  drug. 
Bitter  tonics,  such  as  quinine,  nux  vomicM,  and  gentian, 
are  often  prescribed,  but  in  my  hands  have  been  of  little 
avail.  Such  exercise  as  the  patient  can  take  and  an  out- 
door life  are  especially  serviceable  in  maintaining  an 
appetite. 

Vomiting  oftenest  is  due  to  severe  coughing,  and 
will  cease  if  the  cough  is  lessened  in  severit}^  b\'  ano- 
dynes. More  rarely  it  is  due  to  gastritis,  or  other  com- 
plicating disorders  of  the  stomach.  Generall}^,  resorcin 
and  bismuth  will  prevent  it,  or  the  carbolic-acid  mixture 
described  on  [)nge  154,  from  which  the  antipyrin  may  be 
omitted. 

Diarrhoia  and  constipation  frequently  need  treat- 
ment. The  latter  is  amenable  to  the  usual  laxatives, 
such  as  aloes  and  cascara  sagrada.  The  former  maj' 
result  from  a  catarrhal  or  tubercular  inflammation  of  the 
intestines.  They  are  both  often  persistent  and  recur- 
ring. If  the  diarrlia\a  is  not  severe  the  carbolic-acid 
mixture  just  mentioned  may  suffice  to  check  it.  In 
severer  cases,  and  especially  if  intestinal  ulceration 
exist,  one  of  the  following  forniuhv  will  be  better: — 


Pulmonary  Tuberculosis.  159 

1.  R  01.  gaultheriae,  .         .         .        •.     c.cm.    2  (3ss). 

01.  terebinth.,  .         ..."     10  (Siiss). 
Tinct.  opii,         .         ..."     13  (3iij). 

Sacchar., "30  (5J). 

Acacise, "25  (3vj). 

Aquae,       .         .         .      q.  s.  ad         "   120  (5iv). 
Sig.  :  Make  an  emulsion  and  give  in  teaspoonful  doses, 
diluted  with  water,  every  two  to  six  hours. 

2.  R  Argent,  nitrat.,  .         .     grm.  0.015  (gr,  \). 

Pulv.  opii,  ..."     0.015  (gr.  \). 

Ext.  gentian.,   ..."     0.12    (gr.  ij). 
Sig.  :  A  pill,  to  be  taken  every  four  to  six  hours. 

3.  R  Plumb,  acet.,     .         .         .     grm.  0.12-0.3  (gr.  ii-v). 

Morphiae,  .         .         .         .        "0.008       (gr.  ^). 
Sig.  :  A  pill,  to  be  taken  every  four  to  six  hours. 

Numerous  other  astringents  can  be  used,  but  none 
are  more  generall}'  efficacious  than  those  mentioned. 
Astringents  and  anodynes  can  sometimes  be  usefully 
given  as  enemata.  Food  must  be  administered  with 
care,  so  that  it  will  not  irritate  the  bowels.  It  should 
be  easily  digested,  and  should  not  form  bulky  stools  or 
contain  irritants,  such  as  seeds  or  fruit-stones. 

Ferruginous  preparations  and  the  phosphates  are 
indicated  to  relieve  the  anaemia  which  is  almost  con- 
stantly present  in  phthisis.  They  rarely  meet  the  indi- 
cation, unless  the}^  are  given  during  periods  of  quies- 
cence, Avhen  there  is  no  fever  and  no  active  inflammation. 
Fresh  air,  sunshine,  and  good  food  are  much  more  cer- 
tain to  stimulate  the  blood-creating  tissues  of  the  body. 

The  fever  of  phthisis  is  rarely  treated.  Antipyretics 
certainly  onl}-  temporarily  depress  the  temperature.  The 
course  of  tlie  fever  is  an  intermitting  one.  In  the  milder 
and  most  chronic  cases,  when  a  rise  of  temperature  is 
present  at  all,  it  is  of  short  duration,  and  intervals  of 


160  Diaeaiies  of  the  Lungs. 

noriiml  temperature  are  of  some  hours' duration.  What- 
ever lessens  tlie  tubereuhir  inthunmation  and  sup[)ura- 
tion  will  lessen  or  remove  the  fever. 

Colliquative  sweats  are  of  frequent  occurrence,  and 
are  often  ver}^  persistent.  Thej'  may  be  so  mild  as  to 
be  only  a  little  annoj'ing,  or  so  profuse  as  to  increase 
the  sufferer's  weakness.  So  long  as  the}'  are  not  weak- 
ening, special  treatment  need  not  be  resorted  to.  I  saj- 
this  because  most  drugs  which  are  employed  are  not 
satisfactory,  and  those  that  are  produce  unpleasant  side- 
effects.  Slight  and  occasional  sweating  is  sometimes 
due  to  a  lack  of  air  and  exercise.  It  can  often  be 
lessened  hy  salt,  or  alcohol,  or  vinegar,  or  other  weak 
acid  bath  at  bed-time.  In  those  cases  in  which  sweating 
occurs  only  in  the  early  morning  hours  it  can  frequently 
be  stopped  by  taking  a  drink  of  milk,  or  a  little  of  some 
other  food,  in  the  middle  of  the  night,  or  an  hour  or 
two  before  the  sweating  is  most  apt  to  occur.  Ergot, 
strychnia,  and  digitalis,  each  alone  or  combined,  will 
often  do  good  for  a  time.  They  probably  contract  the 
peripheral  vessels,  thus  lessening  the  blood-supplv  to 
the  glands  of  the  skin,  and  therefore  their  activity.  A 
few  drops  of  nitric  acid  or  other  strong  mineral  acid, 
given  at  l)ed-time  or  even  several  times  daily,  may  be 
useful  temporaril}'.  The  oxide  of  zinc  is  another  remedy 
of  value.  Its  mode  of  action  is  ujdvuown.  It  may  be 
given,  in  doses  of  0.18  gramme  (gr.  iij),  once  to  three 
times  daily.  The  various  })reparations  of  belladonna, 
and  especiall}'  atropia,  are  the  most  uniformly  useful. 
Six  tenths  of  a  milligramme,  a  one-liundredth  of  a  grain 
of  atropia,  administered  at  bed-time,  will  generally 
greatly  lessen  and  often  prevent  the  sweating.  Larger 
doses  mav  be  needed,  or  it  may  h:ive  to  be  "iven  two  or 
three  times  duriug  the  night.     To  be  efTicient,  it  must 


Pulmonary  Tuberculosis.  161 

generally  be  given  in  doses  that  cause  dryness  of  the 
mouth,  and  at  least  slight  dilatation  of  the  pupil.  These 
are  effects  that  to  man}'  are  more  unpleasant  than  sweat- 
ing. When  atropia  is  efficacious  in  small  doses  it  is 
probably  due  to  its  quieting  influence  upon  the  respi- 
ratory centre.  When  it  has  to  be  given  often,  and  in  full 
doses,  it  paralyzes  the  ends  of  the  secreting  nerves. 

Haemoptysis,  if  very  slight,  requires  no  treatment, 
but  ergot  may  be  given  for  a  time  to  prevent  its  return. 
If  at  all  copious,  perfect  quiet  must  be  enjoined.  Even 
coughing  must  often  be  suppressed  by  full  doses  of 
anodynes.  Cold  water  to  drink  and  ice  to  swallow  help 
to  prevent  the  bleeding.  Frequently  ice-bags  ma}-  be 
placed  upon  the  chest  with  advantage.  Ergot  is  always 
useful,  and  can  be  given  b}'  the  mouth  or  hypodermat- 
icalh\  Astringents,  like  the  acetate  of  lead  and  tannic 
acid,  are  also  given.  Turpentine  and  the  subsulphate  of 
iron  may  likewise  be  administered  by  the  stomach  advan- 
tageously. Bleeding  is  rarely  so  copious  as  to  endanger 
life,  and,  when  it  is,  all  these  remedies  may  prove  un- 
availing. When  bleeding  has  ceased  a  recumbent  pos- 
ture should  be  kept  for  some  hours,  so  that  the  obstruct- 
ing clot  will  not  be  loosened  by  exercise.  For  the  same 
reason  the  cough  should  be  mitigated,  and  ergot  should 
be  given  for  some  daA-s. 

Pleurisj^  is  a  frequent  complication,  and  a  painful 
one.  It  must  be  treated  just  as  it  would  be  under  other 
circumstances.  (See  page  178.)  Blisters  are  often  used 
to  check  pleuritic  inflammation.  For  this  purpose  they 
may  be  small, — an  inch  square  or  thereabouts.  They 
also  do  good  when  there  is  fresh  pneumonic  consolida- 
tion. They  then  frequently  hinder  the  extension  of 
consolidation  and  mitigate  the  cough  which  accom- 
panies it. 


162  Diseases  of  the  Lungs. 

Since  the  discover}'  of  the  tubercle  bacillus  much 
has  been  hoped  for  from  the  emplo3'ment  of  antiseptics. 
The}'  have  been  administered  by  inhalation,  b}'  injection 
beneath  the  skin  and  into  the  lungs,  b}'  the  mouth,  and 
even  b}'  the  rectum  ;  but  no  positive  cures  have  been 
effected  b}-  them.  The  best  results  have  been  obtained 
from  antiseptic  inhalations  and  intra-pulmonary  injec- 
tions. Unless  it  is  desirable  to  modif}'  fetid  secretions 
or  laryngeal  and  tracheal  inflammations  the  inhalations 
accomplish  little.  It  is  true  that,  if  a  respirator  is  worn 
for  hours  at  a  time,  all  the  air  in  the  lungs  ma}'  be  more 
or  less  impregnated  by  the  drug.  The  best  antiseptics  for 
use  in  this  way  are  the  volatile  ones,  like  the  terebinthines, 
oil  of  eucalyptus,  thymol,  creasote,  and  carbolic  acid. 
Statistics  do  not  show  as  good  results  for  this  treatment, 
when  applied  to  all  classes  of  cases,  as  for  the  constant 
breathing  of  clean,  fresh  air.  Intra-pulmonary  injec- 
tions have  sometimes  done  good,  but  the  results  obtained 
when  they  are  used  are  so  various  that  they  have  not 
won  the  confidence  of  the  profession. 

I  need  hardly  speak  of  the  numerous  therapeutic 
fads  which  prove  to  be  passing  fashions  and  are  useless 
as  cures.  To  this  class  belong  the  rectal  injections  of 
sulphuretted  hydrogen  gas,  recently  tried  so  extensively, 
and  the  inhalations  of  very  liot  air,  that  have  been 
tested  still  more  recently.  As  yet  no  specific  has  been 
found  for  tubercular  diseases. 

A  year  ago  Koch  issued  to  medical  men  what  is  now 
commonly  known  as  tuberculin.  It  has  been  very  exten- 
sively and  thoroughly  tested  as  a  cure  for  consumption. 
It  is  a  glycerin  extract  of  the  products  of  the  growth  of 
tubercle  bacilli  in  culture  media.  From  it  the  bncilli  and 
germs  are  perfectly  removed,  and  only  the  chemical  prod- 
ucts of  their  growth  remain.     Tuberculin  is  a  brownish. 


Pulmonary  Tuberculosis.  163 

S3^rup-like  fluid.  A  lij'podeiniatic  injection  of  4  minims 
into  a  healtliy  adult  will  cause,  in  tliiee  or  four  hours, 
pains  in  tlie  legs  and  arms,  languor,  inclination  to  cough, 
difficulty  of  breathing, — which  is  quite  intense, — a  pro- 
tracted chill,  and  rise  of  temperature  to  103.2°  F.  One- 
sixth  of  a  minim  usually  produces  slight  pains  in  the 
limbs,  transient  fatigue,  and  sometimes  a  rise  of  one  or 
two  degrees  of  temperature.  This  is  the  smallest  dose 
that  commonly  affects  a  healthy  person.  A  consumptive, 
however,  reacts  moderately  to  one-tenth  of  this  amount ; 
therefore,  treatment  of  this  disease  is  usually  begun 
with  ^Q  minim.  Chill,  fever,  increased  cough,  and  gen- 
eral aches  are  the  symptoms  which  it  commonly  produces 
in  the  consumptive.  After  this  dose  has  been  repeated 
a  few  times,  upon  successive  days,  no  symptoms  are 
caused  by  it.  The  dose  can  then  be  doubled,  and  re- 
peated until  it  i)roduces  no  symptoms.  Thus  the  quan- 
tity administered  can  be  gradually  increased  until 
^  minim,  or  sometimes  a  little  larger  dose,  is  given,  and 
no  reaction  is  produced. 

The  mode  of  action  of  tuberculin  is  peculiar  and 
extremely  interesting.  A  year  has  passed  since  it  began 
to  be  generally  used.  Though  favorable  results  are  still 
occasionally  reported,  its  effects  have  generally  been 
disappointing.  My  own  trials  of  it  have  been  uniformly 
discouraging.  The  drug  is  one  of  great  virulence,  and 
must  be  used  with  the  utmost  caution.  My  first  trial  of 
it  was  upon  a  young  wouian  who  had  plainly  slight  apical 
contraction  of  the  lungs,  no  cavities,  onl}-  a  hacking 
cough,  no  fever  or  night-sweats.  I  used  about  one-half 
the  dose  advised  b3'  Koch  as  a  beginning  one.  No 
febrile  reaction  followed,  but  much  soreness  was  pro- 
duced in  her  chest.  The  same  dose  was  administered 
on  four  different  days,  at  intervals  of  from  two  to  four 


164  Diseases  of  the  Lungs. 

days.  There  was  no  febrile  reaction,  but  the  soreness 
of  the  chest  increased  each  time,  and  was  so  un- 
comfortable that  I  delaj-ed  increasing  the  dose  or  re- 
peating its  administration.  Three  days  after  the  fifth 
injection  a  rise  of  temperature  took  place,  and  in  a  few 
hours  she  was  confined  to  her  bed  with  pleurisy.  An 
extension  of  the  areas  of  dullness  took  place  rapidly.  In 
three  weeks  a  considerable  cavit}^  had  formed  at  one 
apex,  and  at  the  end  of  ten  weeks  the  patient  died.  I 
feel  confident  the  tuberculin  rekindled  an  old  tubercular 
pleuris}  ,  which  in  turn  led  to  pneumonic  infiltration  of 
the  lungs  and  rapid  disintegration  of  them.  I  describe 
this  case  to  illustrate  the  danger  which  even  unusually 
small  doses  sometimes  produce. 

Tuberculin  has  the  peculiar  propert}^  of  exciting- 
active  inflnmmation  about  tubercles.  It  does  not  do 
this — or  accomplishes  it  xery  imperfectl}" — unless  the 
tissue  about  the  tubercles  is  somewhat  vascular.  Often 
ver}'  old  and  verj^j^oung  tubercles  are  not  much  affected 
by  it.  The  inflammation  which  it  excites  sometimes 
causes  encapsulement  and  oftener  cellular  degeneration. 
Koch  says  tuberculin  can  cause  suppuration. 

Chemical  analysis  shows  that  it  contains  albumoses, 
which  constitute  its  active  principles.  By  their  separa- 
tion, possibly,  a  less  dangerous,  but  beneficial,  agent 
may  be  discovered.  The  recent  researches  of  Hunter 
and  Koch  give  promise  of  this. 

The  utility  of  tuberculin  must,  be  looked  upon  as 
still  unestablished.  From  the  statistics  thus  far  gath- 
ered it  is  evidently  not  of  frequent  advantage.  It  is  a 
drug  that  must  be  administered  with  the  greatest  cau- 
tion, and  only  to  patients  who  can  be  closely  watched. 
Each  trial  of  it  must  be  looked  upon  as  an  experiment. 

Koch  recommended  it  to  aid  in  making  a  diagnosis. 


Pulmonary  Tuherodosif^.  .  165 

He  believed  that  onl}-  tuberculous  patients  would  react 
to  one-sixtieth  of  a  minim.  But  it  has  been  shown  that 
tuberculous  patients  do  not  always  react  to  it  even 
when  larger  doses  are  given. 

Prognosis. — The  mortaJity  from  pulmonar}-  consump- 
tion is  very  great.  While  its  ratio  to  all  deaths  is  esti- 
mated tlie  world  over  to  be  one  in  seven,  it  falls  as  low  as 
1  per  cent,  in  some  localities,  and  rises  to  60  and  70  per 
cent,  in  others.  The  frequency'  of  the  occurrence  of  the 
disease  cnn  be  grently  lessened  b}^  improving  the  personal 
hygiene  of  the  people,  and  still  more  b}-  developing  by 
physical  exercises  those  children  and  3^ouths  who  are 
prone  to  the  disease  because  of  defective  growth. 

The  prognosis  for  those  in  whom  the  disease  has 
begun  its  course  must  be  guarded,  but,  unless  great 
feebleness  has  resulted  from  the  extent  of  the  lesions  or 
from  their  destruction  of  the  lung,  it  need  not  be  hope- 
less. Tubercular  consolidation  often  is  made  harmless 
})y  encapsulement,  degeneration,  or  calcification.  Cavi- 
ties may  contract,  and  even  be  obliternted.  Where  sta- 
tistics have  been  carefully  collated  in  the  autopsy-room, 
very  numerous  cases  have  been  found  in  which  tubercu- 
lar lesions  had  cicatrized  and  become  inert.  In  hospital 
cases,  which,  for  the  most  part,  come  from  the  poorest 
people,  because  the}:  neglect  the  beginning  of  illnesses, 
and  in  chronic  ones  continue  to  live  unhygienicallj^  the 
average  duration  of  life  after  pulmonary  consiunption 
sets  in  is  about  two  ^^ears.  This  is  undoubtedly  far 
from  a  correct  average  for  those  who  cnn  have  early 
attention  and  can  afford  to  care  for  themselves  as  they 
should.  The  average  with  them  is  from  five  to  seven 
years.  The  statistics  of  Williams  are  the  most  exten- 
sive and  reliable  that  have  come  nnder  my  observation.* 

*  Pulmonary  Consumption.    By  C.  J.  B.  Williams  and  C.  T.  Williams. 


166  Diseases  of  the  Lungs. 

Of  bis  private  cases,  36  per  cent,  lived  from  one  to  five 
years;  about  one-balf  of  tbese  died  during  tbe  first 
tbree  years.  Sixty-nine  per  cent,  lived  from  five  to 
tbirty  years;  abont  one-balf  of  tbese  died  before  tlie 
tentb  year  of  tbe  disease. 

A  prognosis  cannot  be  based  upon  tbe  number  of 
bacilli  in  tbe  sputa.  If  fever  is  constant,  tbe  chances 
of  permanent  recover}^  are  not  good.  If  tbere  is  a  per- 
sistent loss  of  flesb  tbey  are  not  oood.  On  tlie  otber 
hand,  a  gain  of  flesb  is  always  a  favorable  sign.  If  sud- 
denly a  large  part  of  a  lung  is  consolidated  by  pneu- 
monic inflammation,  it  is  probable  tbe  course  of  tbe  dis- 
ease in  tbat  case  will  be  sbort.  If  consolidation  extend 
slowly  and  by  small  increments,  and  especially  if  long- 
periods  of  quiescence  occur  in  an  individual  case,  a 
long  course,  and  even  ultimate  recover}',  is  probable. 
Tbe  absence  of  fever  and  tbe  possession  of  good  mus- 
cular and  mental  vigor  make  it  possible  always  to  bold 
out  bope  of  an  ultimate  recovery.  Healing  occurs 
oftener  tban  is  supposed.  In  nineteen  tbousand  and 
fifty -tbree  autoi)sies  reported  b}'  various  observers,  ten 
hundred  and  thirty -two  were  found  to  attbrd  evidence 
of  healed  tuberculosis.  In  otber  words,  out  of  nineteen 
thousand  persons,  about  one  thousand,  or  about  4.7  per 
cent.,  liad  had  consumption  and  recovered  from  it.  It 
is  also  a  noteworthy  fact  that  death  occurred  in  these 
cases  of  healed  tuberculosis  with  great  frequency  from 
cancer  (estimated  by  different  observers  at  from  13  to 
41  per  cent.),  lieart  disease  (6  to  -16  per  cent.),  and 
renal,  bladder,  and  genital  diseases  (9  to  12  per  cent.). 


CHAPTER  XIY. 

Neoplasms  OF  the  Lungs. 

Of  neoplasms  011I3'  carcinoma  and  sarcoma  are  of 
importance  or  recognizable  clinically.  A  diagnosis  is 
difficnlt  and  often  impossible,  the  disease  being  mis- 
taken for  some  other  chronic  pulmonar}'  affection.  It 
may  be  secondary  to  new  growths  in  any  part  of  the 
body.  Cancer  of  the  breast  is  oftenest  the  sonrce  of  the 
metastatic  cancer  of  the  lungs.  It  occurs  most  fre- 
qiientl}'  in  those  who  are  advanced  in  3'ears.  The  new- 
formed  tissue  may  be  circumscribed  or  infiltrating. 
Occasionally  cancer  occurs  in  miliar}^  nodules.  The 
pleura  and  the  bronchial,  cervical,  and  axillary  glands 
are  commonl}'  affected.  The  cancer  may  be  medullary, 
scirrhous,  or  epithelial. 

In  its  earliest  development  a  diagnosis  cannot  be 
made.  Gradualh'  increasing  shortness  of  breath  is  felt, 
and  often  oppression  across  the  chest.  Sporadic  and 
harsh  coughing  is  usual.  Sometimes  pleuritic  or  neu- 
ralgic pains  are  distressing.  The  expectorate  frequently 
has  nothing  significant  in  it,  but  becomes  quite  charac- 
teristic when  it  is  reddish  or  blackish  brown  in  color 
jind  gelatinous  in  consistence.  Cancer-cells  can  some- 
times be  found  in  it.  Occasionall}^  the  sputa  is  oft'en- 
sive.  There  is  a  gradual  loss  of  flesh.  The  cancerous 
cachexia  is  developed,  and,  as  in  neoplasms  elsewhere, 
loss  of  appetite,  even  disgust  for  food,  and  vomiting 
become  prominent  symptoms.  Pressure  upon  the 
superior  vena  cava  ma}^  cause  oedema  of  the  neck  and 
side  of  the  chest  and, arm,  or  the  veins  may  be  greatly 

(167) 


168  Diseases  of  the  Lungs. 

distended.  Pressure  on  the  oesophagus  ma}'  obstruct 
or  prevent  deglutition.  Pressure  upon  the  bronchial 
plexus  or  the  involvement  of  the  nerves  in  the  cancer 
may  cause  intense  neuralgia  or  paresis. 

Physical  signs  are  not  pathognomonic.  Irregular 
areas  of  dullness  are  usually'  found.  If  the  bronchi  ai'e 
obstructed  respiratory  sounds  and  vocal  fremitus  will 
be  wanting,  or.  if  the}-  are  patent,  the  former  will  be 
bronchial  and  the  latter  exaggerated.  Rales,  and  some- 
times friction  sounds,  may  be  heard.  Inequalities  in 
the  surface  of  the  chest  or  prominences  are  significant. 

The  prognosis  is  unfavorable.  Death  generally  occurs 
in  from  six  months  to  two  years,  and  is  due  oftenest  to 
gradual  loss  of  strength. 

The  treatment  must  be  supporting  and  sj-mptomatie. 
The  same  remedies  are  used  as  in  other  pulmonarv 
affections  for  similar  symptoms. 


DISEASES  OF  THE  PLEURA. 


CHAPTER  XY. 

Pleurisy. 
Anatomy. — An  iiiflfimmatioii  of  the  lining  membrane 
of  the  plennil  cuvit}'  is  called  pleurisy.  First,  a  con- 
gestion of  the  pleural  vessels  occurs  ;  the  superficial 
cells  become  loosened  and  are  cast  off;  tiie  connective- 
tissue  cells  beneath  swell  and,  it  may  be,  multiply  ;  the 
whole  tissue  is  thickened  by  exuded  lymph  (which 
infiltrates  it),  b}^  leucocytes,  and,  in  spots,  even  hy  red 
blood-cells.  An  entire  pleura  may  be  inflamed  ;  usually, 
how^ever,  only  a  part  is  affected.  The  inflammation 
generall}-  varies  in  intensity  in  places.  The  pleura  at 
one  point  may  be  thickly  crow^ded  with  leucocytes  and 
embrj^onic  cells,  at  another  only  slightl}'  swollen  by  the 
lymph.  The  serous  exudate  ma^^  be  scant,  ma}*  clot 
readil}^  and  deposit  fibrin  upon  the  pleural  surface. 
It  is  then  called  fibrinous,  and  often  dry^  pleurisy. 
When  it  is  purulent  it  is  called  empyema;  when  the 
serous  exudate  is  so  abundant  that  it  accumulates  as  a 
mass  in  the  pleural  cavity  it  is  called  pleurisy  ivith 
effusion,  or  serous  plemHsy.  Pleurisy  may  be  chronic 
in  character  from  its  start.  The  pleura  is  then  per- 
sistentl}' ,  but  moderately,  congested ;  its  connective- 
tissue  and  its  superficial  cells  undergo  considerable 
hyperplasia,  and  little  or  no  exudation  forms  upon  its 
surface.  A  permanent,  and  often  very  considerable, 
thickening  of  the  pleura  is  thus  produced.  An  acute 
pleurisy  may  persist  and  become  chronic. 

8  H  (169) 


170  Diseases  of  the  Pleura. 

Whenever  the  raw  visceral  and  costal  pleural  sur- 
faces are  held  together  they  tend  to  adhere  permanently, 
and  thus  to  obliterate  the  pleural  cavity  or  to  divide  it 
into  compartments.  They  may  unite,  as  it  were,  by  first 
intention.  Adhesions  are  often  temporarily  produced 
by  a  fibrinous  exudate.  A  permanent  band  of  tissue 
may  supplant  the  fibrin  if  the  latter  become  "organ- 
ized." In  this  i)rocess  the  fibrin  fills  with  embryonic 
cells,  which,  while  they  cause  the  fibrin  to  disappear, 
develop  new  and  permanent  connective  tissue. 

The  results  of  fibrinous  pleurisy  are  (1)  resolution. 
The  fibrinous  exudate  may  be  liquefied  and  absorbed, 
the  swelling  of  the  tissue  may  disappear,  and  a  perfect 
restoration  may  take  place.  But  more  frequently  (2) 
permanent  thickening  of  the  pleura  or  (3)  adhesions  are 
left.  The  lung  is  frequently  crippled  b}-  these  thicken- 
ings, since  they  prevent  its  full  expansion.  The  super-' 
ficial  air-cells  are  often  diminished  in  size  or  obliterated 
bj'  an  extension  of  the  inflammation  below  the  pleura 
into  the  lung's  interstitial  tissue,  which  becomes  swol- 
len, and  often  permanentlj^  thickened  and  indurated. 
Dry  pleurisy  may  slighth'  contract  or  deform  the  thorax. 
The  imperfect  lung  expansion,  whose  cause  has  just 
been  ex[)lained,  will  lead  to  a  depression  of  the  over- 
lying thoracic  wall.  Thickening  of  the  costal  pleura 
across  intercostal  spaces  often  prevents  their  expansion 
during  respiration,  and,  therefore,  the  full  distension  of 
these  portions  of  the  thorax. 

The  result  of  a  serous  pleuris}',  or  pleurisy  with 
effusion,  may  be  resolution,  with  or  without  deformity. 
When  serum  parti}'  or  wholly  fills  a  pleural  cavity  the 
lung  must  be  correspondingly  compressed.  If  the  liquid 
remain  in  the  cavity  long  enough  for  the  visceral  pleura 
to  become  permanently  thickened  so  as   to  prevent  or 


Pleurisy.  171 

limit  the  lung's  re-expansion  jind  is  tlien  absorbed,  the 
atmosphere's  weight  will  cause  the  thorax  to  be  pressed  in 
to  meet  the  collapsed  or  partly  expanded  lung.  This  is  a 
common  cause  of  permanent  thoracic  deformity'  in  young 
persons,  but  it  can  produce  only  very  moderate  deform- 
ity in  older  persons,  whose  thorax  has  become  rigid  hy 
more  perfect  ossification  of  its  frame  work.  In  them 
some  liquid  will  remain  if  the  lung  cannot  expand  and 
the  thorax  cannot  be  compressed.  Sometimes,  even 
under  these  conditions,  the  liquid  ma3'  be  absorbed,  and 
the  cavity  which  it  filled  may  be  obliterated  by  an 
emphysema  of  the  opposite  lung,  Avhich  will  crowd  the 
thoracic  organs  into  the  nnexpanded  side  of  the  chest. 
Often  an  abundant  serous  exudate  will  be  completely 
absorbed,  the  lung  will  perfectly  expand,  and  no  de- 
formity will  result.  This  takes  place  whenever  the 
active  inflammation  is  of  short  duration.  A  serous 
exudate  mav  remain  in  tlie  pleural  cavity  for  a  verj' 
long  time.     It  nia\'  also  become  purulent. 

More  frequently  an  enip3'ema  is  such  from  the  begin- 
ning. Circumscribed  emp3'ema  will  rareh^  result  (1)  in 
absorption  and  caseation  or  calcification  of  the  solid 
elements  of  the  pus.  Occasionally,  therefore,  we  find 
•after  death,  within  the  thorax,  a  plate  of  lime,  which 
represents  this  process.  The  liquid  of  the  pus  was  ab- 
sorbed ;  its  solids  were  dried  and  finally  cnlcified.  The 
pus  ma}^  be  (2)  spontaneously  drained  by  ulceration 
through  the  thoracic  wall,  which  produces  a  fistulous 
channel.  It  mu}-  ulcerate  into  the  pericardium,  or  through 
the  diaphragm  into  the  abdomen.  These  are  fatal  results. 
It  also  is  (3)  rarely  drained  spontaneously  through  the 
bronchi  or  stomach  or  intestines  into  which  it  ulcerates. 
If  neither  spontaneous  nor  surgical  drainage  is  estab- 
lished, death  results  as  from  other  large  abscesses. 


172  Diseases  of  the  Fleu7'a. 

Exudates,  both  serous  and  purulent,  cause  displace- 
ment of  the  thoracic  organs.  A  considerable  accumula- 
tion of  fluid  in  one  pleural  cavity-  will  crowd  the  heart 
to  the  opposite  side.  Extra-pericardial  adhesions  may 
then  produce  its  permanent  displacement.  The  thoracic 
viscera  are  usuall}'  depressed.  The  lung  always  floats 
above  the  fluid,  no  matter  what  may  be  the  pcxsition  of 
tlie  thorax.  It  is  also  more  or  less  compressed.  If  the 
entire  cavit}'  is  filled  with  fluid,  it  will  be  completelj^ 
compressed,  and  may  not  occup}'  a  space  larger  than 
one's  hand.     It  is  then  non-vesicular  tiiroughout. 

Causes. — Pleuris}'  ma^-  occur  at  any  age,  but  is  ob- 
served most  frequently  between  the  twentieth  and  fif- 
tieth years.  Males  are  somewhat  of'tener  affected  than 
females.  Those  who  are  in  vigorous  health  are  less  sus- 
ceptible to  it  than  those  who  are  feeble. 

The  malad}'  is  sometimes  primary,  but  oftener  sec- 
ondary to  some  disease  of  the  lungs  or  neighboring 
structures.  The  commonest  cause  of  primar}^  pleuris}' 
is  a  wound  of  the  thorax.  A  penetrating  wound,  or 
even  a  severe  blow,  will  sometimes  excite  it.  If  the 
thoracic  wall  is  deeply  bruised,  or  for  an^'  cause  in- 
flamed, the  pleura  may  be  involved  because  of  its  con- 
tinuity- with  it.  A  few  clinicians  deny  that  primary 
pleurisy  can  be  produced  except  by  a  wound.  But  a 
majorit}'  believe  that  exposure  simultaneously  to  damp 
air  and  to  a  sudden  fall  of  temperature  may,  at  least  in 
feeble  individuals,  provoke  it. 

Pleuris}'  uniformly  accompanies  pneumonia  unless 
the  latter  is  entirely  central,  as  it  may  ver}'  rarely  be. 
It  is  almost  as  uniformly  a  comi)lication  of  tubercular 
disease  of  the  lungs.  It  always  accompanies  this  dis- 
ease unless  the  tubercular  trouble  undergoes  resolution 
in  its  incipiency.      Pleurisy  may  be  one  of  the  earliest 


Pleurisy.  1T3 

phenomena  of  pulmonary  tuberculosis,  but  more  fre- 
quently it  complicates  the  later  stages.  All  other 
superficial  inflammations  of  the  lungs  are  accompanied 
by  pleurisj'.  Peritonitis,  abscess  of  the  liver  and 
spleen,  and  ulcer  of  the  stomach  or  intestines  may  pro- 
duce pleuris}^  b}^  an  extension  of  inflammation  through 
the  diaphragm.  Pleurisy  often  complicates  Bright's 
diseases.  Pyaemia  may  be  its  cause.  Miliary  tubercles 
and  cancerous  nodules  excite  a  surrounding  pleurisy 
when  they  form  in  the  pleura. 

Symptoms. — Pleurisy  is  not  always  accompanied  by 
symptoms.  This  is  especially  true  of  chronic  pleurisy. 
Extensive  pleuritic  adhesions  ma}^  be  found  in  the 
thorax  of  plithisical  patients  in  whom,  before  death, 
pleurisy  was  not  diagnosed.  Often  persistent  localized 
soreness  about  the  chest,  and  especially  at  the  upper 
part  of  the  chest,  in  tuberculous  patients,  is  indicative  of 
chronic  pleuris}-,  although  there  ma^'  be  no  character- 
istic physical  signs  or  subjective  symptoms. 

Acute  fibrinous  or  dry  pleurisy  usually  begins  with 
sharp,  and  often  severe,  pain  in  the  side.  The  pain  is 
localized,  but  the  painful  area  may  increase.  It  is 
aggravated  by  deep  breathing,  and  sometimes  even  b}^ 
restricted  respiration.  A  dry  cough  is  usual,  but  is 
suppressed  as  much  ;is  possible  because  it  aggravates 
the  pain.  Respiration  is  quick.  The  thoracic  move- 
ments are  short,  and  upon  the  affected  side  less  ample 
than  on  the  other.  Tenderness  is  experienced  in  all 
sharply-acute  cases.  It  is  limited,  generally,  to  the 
intercostal  spaces.  A  rigor,  or  a  succession  of  slight 
chills,  announces  the  beginning  of  acute  attacks,  and  is 
followed  by  a  fever.  The  latter  may  last  only  a  few 
hours,  or  may  persist  for  several  days.  It  does  not 
follow   a  typical   course.       It    is   rarely  high,  ranging. 


174  Diseases  of  the  Pleura. 

ordinarily,  from  101°  to  103°  F.  In  subacute  attacks 
these  same  symptoms  are  present,  but  are  much  less 
intense  than  in  the  franklj'-acute  ones.  IMie  physical 
signs  of  dr}-  pleurisy  are  ver}'  important  for  making  a 
positive  diagnosis  of  the  disease.  Occasionally  the  pal- 
pating hand  may  feel  a  friction  fremitus.  Percussion 
usually  reveals  nothing  abnormal.  Sometimes,  if  the 
fibrinous  exudate  is  unusually  abundant,  there  may  be 
a  localized  relative  dullness.  Auscultation  demon- 
strates the  characteristic  friction  sounds.  They  may 
be  loud,  but  more  frequently  they  are  low.  They  are 
characteristically  heard  with  each  respiratory  move- 
ment; sometimes,  however,  they  are  only  audible  with 
deep  inspirations. 

The  ph3'sical  signs  of  pleurisy  with  effusion  are  the 
same  when  the  exudate  is  serous  and  when  it  is  puru- 
lent. If,  as  is  usually  the  case,  the  fluid  enter  a  pleural 
cavity  that  has  not  been  divided  by  pleural  adhesions, 
the  affected  side  will  be  observed  to  move  much  less 
freely  than  the  opposite.  It  will  appear  fuller  because 
the  intercostal  spaces  do  not  show,  and,  therefore,  the 
surface  of  the  chest  on  that  side  seems  smooth.  It  is 
also  rounded  as  the  normal  angles  are  less  acute.  The 
apex-beat  of  the  heart  is  often  displaced.  The  displace- 
ment will  be  to  the  right  if  the  left  cavity  is  filled,  and 
to  the  left  if  the  opposite  one  is.  Usually,  and  espe- 
cially if  the  left  pleural  cavity  contain  the  fluid,  the 
apex-beat  will  be  depressed  because  the  diaphragm  is. 
Vocal  fremitus  will  be  lessened,  and  generally  is  want- 
ing. Percussion  reveals  an  area  of  absolute  dullness 
when  the  fluid  has  accumulated.  Often  it  is  bordered 
above  by  a  semi-tympanitic  space.  This  kind  of  reso- 
nance is  due  to  the  relaxed  condition  of  tiie  partly-com-' 
pressed  lung-tissue.     If  the  fluid  fill  less  than  half  of 


Pleurisy.  175 

the  pleural  cavity,  a  change  in  the  position  of  the  body 
will  cause  the  area  of  dullness  to  shift.     It  will  be  alonor 

o 

the  back  if  the  patient  is  reclining,  and  will  occup}^  the 
bottom  of  the  thorax  if  he  is  sitting  or  standing.  If 
much  more  than  half  the  thorax  is  filled,  it  is  difficult 
to  detect  the  changes  in  the  position  of  the  surface  of 
the  liquid.  The  surface  of  tlie  liquid  is  not  perfectly 
horizontal.  If  the  patient  is  sitting  the  line  of  demar- 
cation between  lung  and  fluid  will  be  found  to  be 
curved.  It  is  lowest  at  the  spine,  rises  gradually  to 
the  axilla,  and  then  falls  a  little  to  the  sternum.  This 
contour  cannot  be  made  out  if  the  thorax  is  ver}^  full. 
The  line  of  separation  is  also  often  difficult  to  locate, 
posteriorly,  because  the  lung  above  the  fluid  is  partly 
solidified,  as  it  is  not  well  filled  if  the  patient  is  con- 
stantl}^  in  the  recumbent  posture.  The  curve  which  the 
surface  of  the  intra-thoracic  fluid  produces  is  due  to  the 
displacement  of  it  by  the  partly-expanded  lung.  Per- 
cussion better  than  inspection  will  demonstrate  cardiac 
displacement,  and,  if  the  fluid  is  in  the  right  pleural 
cavity,  a  depression  of  the  liver. 

The  respiratory  sounds  are  not  transmitted  through 
pleural  effusions  unless  the  lungs  are  solidified.  There- 
fore, auscultation  usually  reveals  an  absence  of  respira- 
tory sounds.  Upon  the  unaffected  side  the  sounds  are 
exaggerated  or  i)uerile.  If  a  pleural  cavity  is  completely 
filled  with  fluid,  bronchial  respiration  may  be  heard 
through  it,  especiall}-  toward  its  upper  part.  These 
sounds  may  be  transmitted  from  the  unaffected  lung, 
but  I  believe  are  most  frequentlj'  from  the  bronchi  in 
a  compressed  and  consolidated  or  carnified  lung;  for  I 
have  never  heard  the  sounds  except  when  the  lung  was 
in  this  condition,  or  the  trachea  and  largest  bronchi 
were  imbedded  in  a  mediastinal  tumor,  throuiih  which 


176  Diseases  of  the  Pleura. 

vibrations  could  be  easily  transmitted  to  the  fluid.  The 
reason  that  lespirntory  sounds  are  not  ordinarily  heard  is 
not  that  fluid  is  not  a  good  conductor  of  sound  (for  it  is), 
but  because  the  vesicuhir  lung-tissue  does  not  transmit 
the  sound  well  to  the  fluid.  The  sounds  are  transmitted 
when  the  lung  loses  its  vesicular  character.  It  may, 
however,  be  as  Garland  urges,  that  such  sounds  are 
transmitted  b^'  the  ribs  and  thoracic  wall. 

Friction  sounds  are  often  heard  at  the  beginning  of 
a  pleuris}^,  and  before  the  pleural  surfaces  are  separated 
1)3'  the  effusion.  They  may  again  be  heard  when  the 
fluid  is  absorbed  and  the  raw  surfaces  come  together. 

The  plhysical  signs  of  encysted  effusions  are  the 
same,  but  the  area  of  dullness  which  the}'  cause  does  not 
change  its  position.  This  area  can  be  mapped  out,  b}' 
percussion  and  by  palpation,  bv  noticing  where  the 
vocal  fremitus  disappears.  If  respirator}-  sounds  are 
wanting  within  the  bounds  thus  established  we  ma}-  feel 
confident  that  an  eff'usion  exists. 

When  a  serous  pleuris}-  begins  often  all  the  symp- 
toms of  a  fibrinous  pleurisy  develop,  but  the  pain  ceases 
as  the  fluid  accumulates  in  quantities  sufficient  to  sepa- 
rate the  inflamed  surfaces.  Respiration  grows  quicker 
and  more  difficult  as  the  lung  becomes  compressed.  If 
the  fluid  accumulate  rapidly  considerable  d3'spnoea  may 
be  felt.  Soon  the  opposite  lung  expands,  and  will  com- 
pensate for  all  moderate  accumulations,  providing  the 
j)atient  is  at  rest,  but  walking  or  an}'  other  form  of 
exertion  will  quicken  the  respiration  or  cause  dyspnoea. 
Cyanosis  is  not  caused  by  pleuritic  efl^usions,  for  the 
blood  is  well  oxygenated  by  the  healthy  lung.  Fever 
usually  accompanies  the  outl)reak  of  the  inflammation, 
as  it  does  that  of  fibrinous  pleurisy,  but  it  may  last  a 
day  or  two  only  ;  in  other  cases  it  persists  for  a  week  or 


Pleurisy.  177 

longer.  It  does  not  follow  an}-  definite  type.  Tlie 
heart  at  first  is  quickened  by  the  fevered  blood,  and 
later  its  increased  motion  is  maintained  by  the  obstruc- 
tion to  respiration  which  the  lung's  compression  causes, 
and  often,  in  part,  by  its  own  displacement  and  conse- 
quent disadvantageous  action.  The  pulse  is  usually  not 
greatly  lessened  in  size  or  firmness.  If,  as  often  hap- 
pens, the  fever  is  of  short  duration  there  may  not  be 
much  loss  of  flesh  or  strength,  but  dyspnoea  prevents 
exertion.  A  serous  effusion  may  persist  for  mau}^ 
weeks.  Usually  it  begins  to  be  re-absorbed  after  two 
weeks  or  thereabouts,  if  resolution  occur  at  all.  Not 
un frequently  it  becomes  purulent. 

The  subjective  symptoms  o^  empyema  are  those  of  a 
serous  pleurisy,  with  those  superadded  which  are  due  to 
the  absorption  of  purulent  matter;  therefore,  the  fever 
is  hectic  in  typo.  Occasionally  chills  recur  with  each 
access  of  temperature,  but  more  frequently  the  temper- 
ature follows  a  very  irregular,  intermittent  course. 
Colliquative  sweating  is  of  nearly  dailj-  occurrence. 
There  is  i)rogressive,  and  often  rapid,  muscular  wasting. 
The  pulse  is  soft,  and  of  medium  or  small  size.  It  is 
as  quick  as  it  is  when  a  serous  eflfusion  exists.  Death 
will  usually  result  from  the  slow  exiiaustion  which 
extensive  and  prolonged  suppuration  produces.  It  may 
result  from  some  of  the  accidents  which  perforation 
may  cause,  as  purulent  pericarditis  or  peritonitis.  The 
course  of  the  disease  covers  a  period  of  from  one  to 
four  weeks,  but,  rarely,  is  more  protracted. 

Diagnosis. — The  diagnosis  of  (h-y  pleuiHsy  can  be 
directl}'  made  whenever  friction  sounds  can  ])e  heard. 
When  they  are  wanting,  pleuritic  pains  must  be  differ- 
entiated from  those  of  intercostal  neuralgia  and  myalgia. 
Neuralgic   pain   is  often   intermittent,  and    is   likely  to 


178  Diseases  of  the  Pleura. 

occur  when  the  breath  is  held  and  respiratory  move- 
ments are  not  made.  The  three  characteristic  points  of 
greatest  tenderness  are  usuall}'  discoverable  when  the 
intercostal  nerves  are  involved.  Neither  coughing  nor 
fever  are  produced  b}'  it ;  it  is  true,  however,  that 
pleuris}'  ma^^  exist  witliout  either.  Muscular  pains  are 
more  shifting  in  character  than  pleuritic,  and  often  are 
felt  simultnneoush"about  the  arms  or  the  opposite  side. 
Palpation  often  makes  it  possible  to  locate  them  in  a 
given  muscle.  A  pleurisy  sufficient  to  cause  pain,  and 
of  a  character  not  to  cause  friction  sounds,  will  only 
occur  when  there  is  a  chronic  inflammatory  lesion  of  the 
lung.  If  no  such  lesion  is  discoverable  the  pain  can  be 
diagnosed  as  not  pleuritic. 

The  ph3-sical  signs  of  an  effusion  into  the  pleural 
cavit}^  are  so  definite  that  it  can  be  diagnosed  directly 
by  the  coincident  (1)  want  of  expansion  of  the  afl^ected 
side,  (2)  prominence  of  the  intercostal  spaces,  (3)  per- 
cussion flatness,  (4)  absence  of  vocal  fremitus,  and  (5) 
almost  uniformly  of  respiratory  sounds.  Pneumonia 
enlargements  of  the  spleen  and  liver,  and  thoracic 
tumors  have  only  dullness  in  common  with  pleuritic 
efl'usions,  but  in  them  the  dullness  is  not  absolute. 
After  the  existence  of  an  eflfusion  has  been  determined, 
it  is  necessary  to  ascertain  whether  the  fluid  is  of 
pleuritic  origin  or  dropsical  (seepage  194.),  and  whether 
it  is  serous  or  purulent.  A  hectic  fever  is  suggestive 
of  empyema,  but  is  not  positive  proof.  We  can  only 
decide  positively  after  an  experimental  aspiration  with 
a  hypodermatic  or  aspirator  needle. 

Treatment.— The  soreness  which  is  often  felt  in 
chronic  pleurisy,  and  the  momentary  but  sharp  pleu- 
ritic stitches  which  accompany  mild  acute  pleurisy,  are 
usually  relieved  by  counter-irritants.    A  mustard-plaster 


Pleurisy.  179 

may  suffice,  but  a  small  fl3^-blister  is  surer.  The  latter 
need  not  be  large.  One  an  incli  square  is  sufficient.  *In 
sliarply-acute  eases  a  larger  blister  is  more  effective,  and 
should  be  followed  by  fomentations.  Instead  of  apply- 
ing counter-irritants  the  affected  side  of  the  chest  mny 
be  "  strapped."  That  is,  strips  of  adhesive  plaster  may 
be  so  laid  on  that  they  will  prevent  or  limit  the  motion 
of  the  ribs,  and  thus  check  the  rubbing  of  the  raw  pleu- 
ral surfaces  against  one  another.  Very  great  relief  is 
often  afforded  by  this  procedure.  The  strips  should  be 
long,  and  should  be  applied  at  right  angles  to  the  ribs, 
so  that  they  will  bind  them  together  and  keep  the  inter- 
costal si)aces  as  small  as  possible. 

Oi)iates  must  be  used  whenever  the  pains  are  very 
severe.  Often  drugs  are  contra-indicated,  as  the}-  tend 
to  diminish  the  appetite,  or  even  to  cause  nausea.  Fre- 
quently a  small  blister  will  be  found  to  i)roduce  more 
permanent  relief  than  an  opiate.  Morphine  and  codeia 
are  the  preparations  oftenest  employed.  Just  as  in 
pneumonia  calomel  is  frequently  used  (see  page  101) 
because  it  seems  to  modify  the  exudate  and  prevent  its 
being  so  fibrinous,  and  as  it  seems  to  promote  the  ab- 
sorption of  such  exudates,  it  is  used  in  fibrinous  pleu- 
risy. It  may  be  given,  at  the  beginning  of  the  attack,  in 
two  or  three  doses  of  1  grain  each,  or,  perhaps  more 
advantageously,  in  small  doses  of  \  grain  each,  which 
can  be  administered  for  two  or  three,  and  sometimes 
four  or  five,  days.  Even  mild  salivation  should  be 
avoided.  Purgation  is  usually  not  caused,  as  opiates 
must  generally  be  simultaneously^  given. 

Antipyretics  are  of  little  use  unless  the  high  temper- 
ature causes  delirium,  as  it  often  does  in  children.  An- 
tipyrin  or  acetanilid  will  be  found  to  afford  relief  to  this 
symptom  by  depressing  the  temperature. 


180  Diseases  of  the  Pleura. 

It  is  desirable  that  the  bowels  should  be  kept  regu- 
lar/ At  the  beginning-  of  the  attack  moderate  depletion, 
by  provoking  a  few  watery  movements  from  the  bowels, 
does  good.  This  can  be  provoked  by  administering  two 
or  three  powders,  at  intervals  of  two  hours,  of  calomel 
and  bicarbonate  of  soda,  containing  5  grains  of  each 
ingredient,  or  by  giving  the  liquid  citrate  of  magnesia, 
or  some  similar  prei)aration.  While  there  is  fever  the 
diet  should  be  simple.  If  there  is  no  fever  the  regimen 
of  health  may  be  followed. 

The  first  or  painful  stage  of  pleurisy  with  effusion 
must  be  treated  the  same  as  fibrinous  pleurisy.  As 
soon  as  fluid  is  found  to  be  accumulating  the  patient 
should  be  placed  upon  a  dry  diet,  and  liquids  should 
be  withheld  as  much  as  possible.  A  serous  efi'usion  can 
often  be  checked  in  this  wa}',  and  its  re-absorption 
hastened. 

There  are  a  number  of  drugs  commonly  emplo^'ed  to 
promote  re-absorption  of  an  exudate,  but  with  doubtful 
utility.  These  are,  especialh',  iodine  painted  upon  the 
surface  of  tlie  thorax  ;  sodium  chloride  and  potassium  or 
sodium  iodide  administered  internally.  Common  salt  is 
occasionailv  given, — in  as  large  amounts  and  as  fre- 
quently as  the  patient  can  bear  it.  It  is  believed  that  if 
the  blood  can  be  made  strongh^  saline  a  demand  on  the 
part  of  the  system  will  be  created  for  water,  which  will  be 
satisfied  by  the  absorption  of  the  exudate  if  water  is  not 
drunk.  The  good  effect  of  the  iodides  probably  results 
from  their  increasing  diuresis.  They  are  not,  however, 
as  efficient  diuretics  as  the  acetate  of  potash  or  am- 
monin.  Digit nlis  is  usuall}'  combined  with  these  in  a 
diuretic  mixtur<\  but  its  employment  must  be  governed 
by  the  rapidity  of  the  pulse.  If  it  is  slow  it  may  pro- 
voke vomiting,  by  making  the  heart  too  slow  or  irreg- 


Flevrisij.  181 

nlar.  Diuretics  have  almost  invariably  disappointed  me 
when  I  have  relied  upon  them  alone  to  promote  absorp- 
tion of  the  exudate,  but  they  are  useful  adjuvants  to 
other  methods  of  depletion.  Saline  cathartics  may  be 
used  with  them  advantageousl}^,  but  should  not  be 
pushed  to  that  extent  that  the^^  produce  much  weak- 
ness. Diaphoretics  ma}^  also  be  used  with  one  or  the 
other  of  these  methods  of  depletion.  Sweating  pro- 
voked by  dr}'  heat  (see  page  270.)  is  usuall}'  the  best. 
Pilocarpine  may  be  used,  but  it  causes  an  enfeeblement 
of  the  circulation, — wdiicli  is  contra-indicated  in  some 
cases, — and  often  very  uncomfortable  salivation.  De- 
pleting agents  cannot  be  successfully  used  if  the  patient 
is  very  feeble,  and  the}'  often  prove  useless,  even  when 
employed  as  thoroughl}^  as  is  possible.  Aspiration 
affords  a  means  of  withdrawing  the  fluid  promptly  and 
surely,  and,  if  properly  done,  without  danger.  If  the 
amount  of  the  eftusion  is  large  it  should  be  preferred  to 
any  of  the  methods  that  are  emplo^'ed  to  promote 
absorption.  The  indications  for  aspiration  are  usualh' 
snid  to  be:  (1)  if  the  effusion  cause  marked  displace- 
ment of  the  heart;  (2)  if  the  fluid  remain  without 
change  or  increases  in  amount  during  three  or  four 
weeks.  I  have  never  felt  justified  in  waiting  three  or 
four  weeks  before  aspirating.  If  there  is  much  fever, 
especially  if  it  is  hectic  in  character,  I  believe  that  one 
should  not  delay  more  than  ten  da3^s  before  positivel}' 
determining  whether  the  fluid  is  serous  or  purulent.  If 
aspiration  is  practiced,  in  order  to  establish  a  diagnosis 
some  of  the  fluid  may  as  well  be  withdrawn  while  the 
needle  is  in  place.  If  there  is  no  fever  it  is  not  expe- 
dient to  w\ait  more  than  ten  days  before  aspirating  if  the 
fluid  does  not  in  that  time  begin  to  diminish  in  amount ; 
for  the  longer  the  lung  is  allowed  to  be  compressed,  the 


182  Diseases  of  the  Pleura. 

more  danger  is  there  that  a  thickening  of  its  pleura  or 
interstitial  tissue  will  prevent  its  re-expansion. 

If  tispi ration  is  to  be  practiced,  the  thorax  can  be 
best  punctured  in  the  lower  part  of  the  axilhuy  space. 
The  patient  ma}^  sit  or  recline  while  the  fluid  is  being 
withdrawn.  It'  he  is  recumbent  he  should  lie  partly 
upon  the  affected  side,  but  with  it  overhanging  the  edge 
of  the  bed.  The  fluid  ma}-  be  withdrawn  until  coughing 
is  provoked,  or  decided  distress  in  the  side  is  produced 
from  the  dilatation  of  the  compressed  lung.  It  is  not 
necessary  to  withdraw  all  the  fluid  within  the  pleura, 
for  if  its  quantit}-  is  lessened  an  absorption  of  the  rest 
will,  as  a  rule,  rapidl}^  follow.  Unfortunately,  it  will 
occasionally  re-accumulate.  Aspiration  ma}^  be  repeated 
as  often  as  is  necessary.  It  is  only  dangerous  if  the 
needles  are  not  aseptic,  or  if  a  piece  of  emphysematous 
lung  is  accidentalh'  punctured,  for  the  former  mischance 
may  produce  purulent  inflammation  and  the  latter  pneu- 
mothorax. After  aspiration,  a  physical  examination 
will  demonstrate  that  the  area  of  dullness  is  lessened, 
and  that  respiratory  sounds  can  be  heard  over  a  greater 
portion  of  the  chest.  In  the  rare  cases  in  which  re- 
absorption  cannot  be  eff"ected  excision  of  the  ribs  may 
be  resorted  to ;  but  it  should  be  avoided  unless  every 
other  resource  fails  after  patient  and  persevering  trinl. 

If  pus  is  found  in  the  pleural  cavity  it  should  be 
drained  therefrom  at  once.  A  cessation  of  suppuration 
within  the  pleural  cavit}^  is  efl^ected  by  the  permanent 
union  of  the  visceral  and  costal  pleura,  which  results  in 
the  obliteration  of  the  cavity.  This  can  only  be  accom- 
plished while  the  luug  is  able  to  expand  and  fill  the 
cavity  after  the  pus  is  withdrawn.  It  is  extremel}'  im- 
portant that  an  empyema  should  be  drained  as  early  as 
possible   before  the  lung's  expansibility  is  lessened  by 


Pleurisy.  183 

adhesions  or  a  thickened  pleura.  Drainage  is  best 
established  by  making  an  incision  through  an  inter- 
costal space, — which  is  as  low  as  will  admit  one  to  the 
pleural  cavity, — and  by  inserting  through  it  a  large  and 
closely  fitting  drainage-tube.  A  tube  with  a  flange, 
which  will  prevent  its  slipping  into  the  thorax,  is  to  be 
preferred.  If  it  is  not  at  hand,  this  accident  must  other- 
wise be  guarded  against.  If  the  operation  is  performed 
early  and  while  the  lung's  expansibility  is  good  a  single 
drainage-tube  will  suffice,  providing  it  is  managed  so 
that  the  lung  is  kept  inflated.  This  can  be  accomplished 
b\'  opening  the  drainage-tube  only  during  inspiration, 
when  the  pus  will  be  forced  out  by  the  dilating  lung. 
During  expiration  the  tube  must  be  closely  compressed. 
By  thus  pumping  the  cavity  it  can  be  thoroughly  emp- 
tied. After  it  has  been  emptied  in  this  way  the  tube 
ma}'  be  temporarily  corked.  The  procedure  must  be 
repeated  whenever  an  ounce  or  two  of  fluid  accumulates. 
This  may,  at  first,  necessitate  its  frequent  repetition, 
especially  if  the  pyogenic  surface  is  extensive.  But,  usu- 
allj',  in  a  few  days  a  part  of  the  cavity  will  be  obliterated, 
and  it  will  have  to  be  drained  less  and  less  frequently  as 
less  pus  is  formed.  The  pyogenic  cavity  can  be  washed 
with  antiseptic  solutions,  and  they  can  be  aspirated  out 
or  pumped  out  in  the  same  waj'  that  the  pus  is.  This 
very  simple  metiiod  for  preventing  the  access  of  air  to 
the  pleural  cavit}^  and  consequent  compression  of  the 
lung,  was  first  devised  by  Prof.  Edmund  Andrews,  of 
Cliicago.  Others  have  contrived  more  elaborate  appli- 
ances, containing  a  valve  in  tiie  drainage-tube,  that 
makes  constant  drainage  possible.  I  have  seen  An- 
drews's method  repeatedly  emploj^ed,  and  with  results 
that  could  not  be  bettered.  A  more  usual  method  is  to 
insert,  at  different  points,  into  the  pleural  cavity  several 


184  Diseases  of  the  Pleura. 

drainage-tubes,  letting  the  iiir  enter  freelj^,  and  trusting 
to  frequent  washing  and  a  depression  of  the  thorax  and 
distension  of  the  opi)osite  lung  to  obliterate  the  cavity. 
This  is  not  so  uniformly  successful  as  the  other  method 
in  the  cases  for  which  it  is  adapted.  If,  however,  the 
lung  cannot  fully  expand  several  orifices  for  drainage 
are  usually  needed,  and  should  be  so  placed  that  they 
will  make  it  possible  to  thoroughly  drain  and  wash  the 
cavit}'. 

Often  it  is  impossible  to  obliterate  completely  a 
large  cavit^',  because  the  lungs  cannot  sufficientl}"  ex- 
pand or  the  thoracic  wall  sufRcienth'  contract.  In  such 
cases  resection  of  a  part  of  the  ribs  ma}'  be  resorted  to, 
in  order  to  bring  together  the  pleural  surfaces  and  make 
possible  their  adhesion. 

Resection  is  a  grave  operation,  and  at  the  best  entails 
much  discomfort  upon  those  operated  on.  I  believe  it 
should  be  resorted  to  only  after  other  methods  have 
been  most  faithfully  tried  and  found  unsuccessful.  Occa- 
sionall}'  a  fistulous  opening  will  persist  in  the  side  for 
months,  from  which  a  few  drachms  of  pus  will  daily  flow. 
The  patient  will  regain  flesh  and  strength  in  spite  of  this, 
and  be  able  to  do  varied  and  even  laborious  work.  Twice 
in  just  such  cases  I  have  seen  resection  tried  and  fol- 
lowed b}'  a  fatal  result  within  two  weeks.  The  prospect 
of  months,  and  perhaps  of  years,  of  comparative  health 
was  good  before  the  operation.  I  have  seen  in  other 
similar  cases  such  fistulse  and  discharges  persist  for  a 
year  and  more,  and  ultimatel}'  perfect  recover}'  occur. 
If  the  pyogenic  cavit}^  cannot  be  easily  closed,  though 
drainage  restore  the  patient  to  a  condition  of  moder- 
ate strength  and  entire  freedom  from  fever,  I  advise 
trying  the  inhalation  of  compressed  air,  or  a  residence 
at  a  high  altitude,  or  enforced  deep  breathing  and  pos- 


Pleurisy.  185 

tural  breathing,  which  will  distend  the  lungs  to  the 
greatest  extent  possible. 

Perfect  drainage  and  antiseptic  washings  of  an 
empj'ema  will  usually  promptly  remove  the  fever,  as 
well  as  the  night-sweats  and  the  other  symptoms  of 
septic  poisoning.  The  appetite  and  ability  to  digest 
food  return  with  their  disappearance.  As  the  drain 
upon  the  system  is  great,  the  maintenance  of  strength 
is  all-important.  Food  should  be  given  ns  freel3'  as  the 
stomach's  digestive  power  will  permit.  It  must  be 
easily  digested  and  highly  nutritious.  In  conditions 
of  great  weakness  milk,  eggs,  custards,  and  beef-juice 
form  the  best  diet.  As  strength  returns  it  can  l)e 
varied,  and  made  more  nearly  that  of  a  healthy  person. 

Often,  before  drainage  is  established,  the  system  is 
so  fully  poisoned  by  absorbed  septic  matters  that  great 
enfeeblement  of  the  whole  bodj^  exists.  The  pulse  ma}' 
be  very  small,  soft,  and  quick.  Vomiting  may  be  of 
frequent  occurrence,  and  diarrhoea  and  night-sweating 
H!ay  be  exhausting.  If  drainage  and  the  consequent 
removal  of  the  source  of  intoxication  do  not  cause 
these  symptoms  to  disappear,  the  case  must  be  treated 
symptomaticall}'.  For  instance,  the  cardiac  weakness 
must  be  counteracted  b}'  digitalis  or  one  of  its  congeners, 
and  the  vomiting  and  diarrhoea  must  be  checked  b^'  the 
drugs  usuallj'  emploj^ed  to  combat  such  symptoms. 

Malformations  of  the  chest  which  result  from  pleu- 
risy can  frequentl}'  be  corrected.  This  is  especially 
possible  during  the  first  third  of  life.  They  are  cor- 
rected b}'  dilating  the  lung  and  by  bringing  about  a 
hj'pertroph}'  of  its  tissue.  These  objects  can  be  accom- 
plished b}^  persistently  exercising  the  crippled  lung. 
Frequent  enforced  deep  breathing  is  useful.  Postural 
breathing  is  still  more  useful.     For  example,  as  a  long 

H» 


186  Diseases  of  the  Pleura. 

and  deep  inspinition  is  being  taken  the  patient  maj^  lean 
to  the  unaffected  side,  so  that  its  lung  cannot  easily  ex- 
pand, while  every  opportunit}'  is  given  to  its  crippled 
mate.  A  still  better  postural  exercise  consists  in  grasp- 
ing, during  complete  expiration,  the  thigh  on  the  un- 
affected side  with  the  hand  of  the  same  side,  and  in  the 
slow  raising  of  the  opposite  arm  from  the  side  by 
swinging  it  outward  and  upward,  as  an  inspiration  is 
slowl}'  and  deepl}'  made,  until  it  is  stretched  as  high  as 
possible  above  the  head.  Other  forms  of  postural  res- 
piration can  be  devised  that  are  better  suited  to  the 
location  of  certain  deformities.  The  inhalation  of  com- 
pressed air  is  exceedingl}'  useful.  A  residence  in  high 
altitudes  will  also  help  to  expand  the  chest.  But  thej- 
should  be  combined  with  postural  respiration.  Running, 
mountain-climbing,  and  other  exercises  that  especially 
lead  to  involuntary  deep  breathing  and  lung  develop- 
ment are  useful  aids. 

Prognosis. — The  prognosis  of  pleurisy  must  depend 
ujDon  its  character  and  cause.  For  primary  drj^  pleu- 
ris}^  the  prognosis  is  favorable.  For  dry  pleurisy  at  the 
apex,  especially  if  it  is  subacute  or  chronic,  it  must  be 
guarded,  as  tuberculosis  is  its  usual  cause.  As  a  rule, 
perfect  resolution  will  take  place  in  serous  pleurisy, 
especially  if  a  large  amount  of  fluid  does  not  accumu- 
late. By  aspiration  most  serous  pleurisies  in  which 
effusions  have  been  extensive  will  undergo  resolution. 
Purulent  pleurisy  very  rarely  recovers  spontaneously. 
By  surgical  treatment  most  cases  can  be  cured,  and  if  it 
is  applied  at  the  beginning  of  the  disease  almost  every 
case  can  be  saved. 


CHAPTER  XYI. 

Pneumothorax. 

Causes. — Air  mrel}-  exists  long  in  the  thoracic 
cavities  without  exciting  inflammation,  which  is  accom- 
panied by  a  fibrinous,  or  oftener  serous  or  purulent, 
effusion. 

Air  may  gain  access  to  the  pleural  cavity  from  with- 
out through  a  wound,  such  as  a  stab  or  bullet  wouud, 
but  oftenest  it  is  admitted  b}^  perforation  of  a  lung, 
which  permits  its  air  to  escape.  A  broken  rib  ma}'  tear 
tiie  lung  and  cause  pneumothorax,  though  the  chest  wall 
is  not  opened.  More  rarely,  after  adhesive  peritonitis 
has  glued  the  stomach  or  an  intestinal  loop  to  the 
diaphragm,  tliey  are  perforated  by  ulceration,  and  per- 
mit air  or  gas  to  escape  from  them  into  the  pleura.  The 
lung  is  oftenest  perforated  by  the  rupture  of  a  phthisical 
cavity.  This  rarely  occurs,  except  in  cases  of  rapidl}' 
developed  phthisis,  for,  if  the  disease  is  chronic,  either 
the  pleura  becomes  greatly  thickened  over  the  vomica 
or  the  costal  and  visceral  surfaces  adhere  and  obliterate 
the  thoracic  cavity.  Gangrene  and  abscess  of  the  lung- 
may  lead  to  perforation  of  the  pleura.  Lung-tissue 
which  is  emphysematously  distended  rarely  gives  wa}^, 
and  produces  a  minute  channel  by  which  air  can  escape 
from  the  lung.  Forced  respiration,  associated  with 
violent  physical  exertion,  ma}'  produce  such  a  rupture, 
and,  in  extremely  rare  cases,  seems  to  be  the  sole  cause 
of  pneumothorax.  An  empyema  may  ulcerate  through 
the  pleura,  and  the  pus  ma}^  escape  by  a  bronchus.  The 
hole    in    the    pleura   thus   formed    is    rarely  the    cause 

"(187)  • 


188  Diseases  of  the  Pleura. 

of  pneumothorax.  It  has  been  asserted  that  purulent 
and  putrid  fluids  in  the  pleural  sac  may  produce  gas  and 
an  apparent  pneumothorax.  It  is  very  doubtful  if  this 
ever  occurs.  A  single  opening  may  admit  the  air  to 
the  pleural  sac,  but  often  several  do.  Pneumothorax  is 
very  rare  in  both  pleurae. 

Varieties. — If  the  channel  b}-  which  air  enters  the 
pleural  cavity  remain  constantl}'  open,  it  is  called  "open 
pneumothorax'';  if  closed,  "closed  pneumothorax": 
and  if  it  is  open  during  inspiration  and  closed  during 
expiration,  it  is  called  "valvular  pneumothorax."  A 
permanent  closure  may  be  effected  by  a  fibrinous  exudate, 
which  becomes,  at  least  in  part,  organized  ;  or  it  may 
result  from  compression  of  the  lung.  In  closed  and 
valvular  pneumothorax  the  air  within  the  pleura  is 
under  more  than  atmospheric  pressure,  and  if  an  exit  is 
afforded  it  will  escape  with  a  hiss.  A  valvular  pneumo- 
thorax will  be  formed  when  the  perforation  through  the 
pleura  is  an  oblique  one.  The  air  of  a  closed  and  open 
pneumothorax  varies  in  composition.  Carbonic-acid 
gas  is  more  abundant,  and  oxygen  less,  in  the  closed. 
Often  air  can  gain  access  to  only  })art  of  the  pleural 
cavit}',  because  of  adhesions. 

Symptoms. — The  onset  of  pneumothorax  is  generall}' 
sudden.  If  it  is  due  to  rupture  of  the  lung,  as  it 
commonly  is,  a  pain  is  suddenly  felt  in  one  side.  The 
feeling  is  described  sometimes  as  like  the  breaking  or 
tearing  of  something.  It  ma}-  be  agonizing  or  moder- 
ately severe.  It  ma}'  be  transitory  or  may  persist  for 
some  hours.  When  persistent  it  is  ver}-  like  the  pain 
of  pleurisy,  and  may  be  due  to  inflammation.  Rapidly 
after  the  pain  begins  dyspna\a  of  varying  degrees  of 
intensity  arises.  If  the  pleural  sac  quickl}'  fill  with 
air,  the  lung  upon  that   side   will  partly  or  wholly  col- 


Pneumothorax.  189 

lapse,  and  the  heart  may  be  displaced.  The  heart  will 
beat  rapidly,  because  of  the  interference  with  the  pul- 
monar}'  circulation  which  tlie  collapse  causes.  Rarely 
the  development  of  pneumothorax  is  accompanied  by 
the  symptoms  of  collapse.  The  temperature  falls  ;  the 
countenance  is  anxious  and  gray  ;  the  skin  is  cold,  and 
often  clammy  ;  the  lips  are  purplish  ;  the  pulse  is  small, 
soft,  120  or  more  per  minute.  Death  may  occur  in  a  few 
minutes,  or  in  a  few  hours,  from  the  great  disturbance 
suddenly  caused  to  respiration  and  circulation.  Usualh^ 
death  is  not  sudden.  If  it  occur  at  all,  it  is  after  days 
or  weeks.  Recovery  ma}^  take  place,  but  does  not  do 
so  commonl3\  The  primarj^  disease — which  is  usuall}^ 
phthisis,  or  abscess,  or  emphj'sema — causes  death,  or  a 
complicating  purulent  pleuris}^  iii'>y.  If  recovery  take 
place,  obstruction  to  the  ingress  of  the  air  occurs,  a 
serous  exudate  replaces  it  as  absorption  progresses,  and 
finally  the  hydrothorax  may  be  relieved  b}^  treatment  or 
spontaneous  absorption.  If  the  air  in  the  pleural  cavitj^ 
is  not  large  or  fills  only  a  section  of  it,  absorption  may 
take  place  without  being  followed  b}^  a  serous  exudate. 
Commonly  pneumothorax  provokes  inflammation  of  the 
pleura  and  a  complicating  serous  or  purulent  inflamma- 
tion, 

A  diagnosis  can  only  be  made  from  the  physical 
signs  which  pneumothorax  causes.  The  affected  side  is 
'distended.  The  intercostal  spnces  are  wide  or  bulging. 
Respiratory  movements  are  slight  or  wanting,  while 
exaggerated  on  the  other  side.  Vocal  fremitus  is  usually 
absent.  The  resonance  is  great.  Percussion  sounds 
are  loud  and  clear.  They  may  be  tympanitic,  but  usualh' 
are  hj'per-resonant  only,  because  the  distension  of  the 
thorax-wall  prevents  the  production  of  a  tympanitic 
note.     The  area  of  resonance  will  be  much  greater  than 


190  Diseases  of  the  Pleura. 

usual  if  the  wliole  of  a  pleural  cavity  is  filled  with  air. 
The  liver  will  be  depressed  if  the  right  side  is  affected, 
and  the  heart  may  be  crowded  wholly  into  the  right 
thorax  while  the  left  side  is  affected.  If  the  heart  is 
thus  dis[)laced,  its  pulsations  will  be  seen  and  felt  to  the 
right  of  the  sternum,  and  its  sounds  will  be  heard  there 
and  will  be  lacking  on  the  left  side.  Auscultation  may 
demonstrate  an  entire  absence  of  respirator}'  sounds. 
Oftener  they  are  audible,  but  have  a  characteristic 
metallic  qualit}'.  There  may  be  amphoric  metallic 
respiration.  This  occurs  when  there  is  an  open  pneumo- 
thorax, or  the  sounds  ma}'  be  the  usual  bronchial  or 
tracheal  ones,  which  acquire  a  metallic  qualit}'  when 
they  are  transmitted  through  the  air  in  the  pleura. 
Metallic  rales  or  tinklings  are  often  heard.  If,  while 
auscultation  is  practiced,  a  plexi meter  is  struck  by  the 
handle  of  a  percussion  hammer  or  other  solid  bod}'',  a 
metallic  percussion  sound  will  be  heard.  If,  as  is  so 
often  the  case,  an  effusion  as  well  as  air  is  in  the  pleural 
sac,  the  usual  sio;ns  of  a  pleural  effusion  w'ill  be  found 
over  the  most  dependent  part  of  the  thorax.  The  sur- 
face of  the  fluid  will  not  be  curved,  as  in  ordinary  pleural 
effusions,  but  will  be  horizontal.  It  will  change  with 
changes  in  the  position  of  the  body.  Moreover,  the 
heiglit  of  tlie  metallic  sounds  produced  by  the  pneumo- 
thorax will  vnry  with  changes  in  the  position  of  the 
body,  because  of  the  resulting  change  in  the  shape  of ' 
the  air-space.  Sudden  movements  of  the  body  may 
cause  a  metallic  splashing. 

Diagnosis. — A  diagnosis  is  usually  not  difficult,  if 
the  physical  signs  are  sought  for.  It  may  be  difficult 
to  differentiate  between  a  circumscribed  pneumothorax 
and  a  large,  superficial  i)ulmontiry  cavity.  The  former 
is  oftenest  in  the  lower  part  of  the  thorax,  the  latter  in 


Pneumothorax,  191 

the  upper.  The  iiitercostiil  spaces  are  usually  wide  or 
bulging  in  the  former,  and  contracted  or  retracted  in 
the  latter.  Vocal  fremitus  is  slight  or  wanting  in  the 
former  and  may  be  strong  in  the  latter.  Cardiac  dis- 
placement is  indicative  of  pneumothorax. 

Treatment. — The  indications  for  treatment  are  :  (1) 
'to  relieve  pain  while  it  exists ;  (2)  to  strengthen  the 
heart,  if  collapse  occurs;  (3)  to  relieve  dyspncea ;  (4) 
to  treat  pleuritic  inflammation  that  may  complicate  the 
pneumothorax. 

The  pain  which  the  pulmonary  rupture  causes  is 
usually  transitory.  If,  as  rarel}'  happens,  it  is  severe, 
one  or  two  doses  of  morphine  may  be  needed.  Per- 
sistent pain  is  usually  due  to  pleuris}^  Morphine  or 
codeia  may  be  needed  for  its  relief.  Often  counter- 
irritants  and  fomentations  will  answer  as  well. 

If  the  patient  is  in  a  state  of  collapse,  cardiac  and 
diffusible  stimulants  are  required.  Ammonia  by  inhala- 
tion and  by  the  stomach  produces  prompt  but  transitory 
effects.  Camphor  acts  in  the  same  way,  b}'  stimulating 
the  heart,  and  can  be  given  hypodermaticall}^  in  an  oil 
solution.  (See  page  101.)  Digitalis  and  strophanthus 
produce  more  lasting  but  less  prompt  effects. 

The  dyspnoea  which  is  due  to  a  sudden  compression 
of  the  lungs  and  interference  with  the  circulation  ma}' 
endanger  life.  Often  those  who  have  not  suffered  from 
dyspnoea  before  the  pulmonar}'  collapse  occurs  are  at 
once  overwhelmed  and  fatallj-  suffocated,  while  those 
who  are  habituated  to  dyspnoea  b}'  other  lung-lesions 
may  not  be  endangered  b}'  a  similar  accident.  Dj'spnoea 
produced  in  this  way  cannot  be  easil}'  relieved.  Aspira- 
tion of  tiie  air  within  the  pleural  sac  has  been  resorted 
to.  It  can  do  no  good  unless  the  pneumothorax  is  a 
closed    one.     Puring   the    first    few    hours,    while    the 


192  Diseases  of  the  Pleura. 

dyspnoea  is  most  keenly  felt,  it  is  least  likely  to  be 
closed.  After  three  or  four  dixys  a  small  perforation 
ma}'  close,  and  then  the  cavity  ma}^  be  aspirated  of  its 
air.  Often,  just  as  when  liquid  effusions  are  withdrawn, 
coughing  is  excited  or  thoracic  distress  produced  b}- 
aspiration.  A  part  onl}'  of  the  air  can  then  be  with- 
drawn. Indeed,  it  is  undesirable  to  remove  it  all,  for 
b}'  so  doing  there  is  danger  of  stretching  the  weak 
lung,  so  that  it  will  again  rupture. 

Emp3'ema  and  serous  effusions  must  be  treated  as 
the}'  would  be  when  there  is  no  pneumothorax.  The 
former  should  be  drained  as  soon  as  possible.  If  the 
pneumothorax  is  a  closed  one,  drainage  ma}'  be  followed 
with  a  partial  expansion  of  the  lung,  and  gradually  a 
complete  expansion.  Under  these  circumstances,  ad- 
hesive pleurisy  may  gradually  obliterate  the  cavity,  and 
the  suppuration  may  cease.  If  the  pneumothorax  is 
open  and  the  lung  cannot  re-expand,  not  only  is  drain- 
age needed,  but  usually  resection  of  the  ribs,  to  produce 
contact  of  the  pleural  surfaces. 

Rest  should  be  enjoined  from  the  first,  that  no  bodily 
exertion  may  widen  the  rent  or  prevent  its  closing.  As 
the  only  hope  of  recovery  lies  in  the  preservation  of 
life  until  absorption  of  the  air  can  be  brought  about  or 
complicnting  pleurisy  cured,  foods  must  be  judiciously 
administered. 

Pneumothorax  from  penetrating  wounds  is  often 
curable.  The  wound  must  be  closed.  The  air  may  be 
partly  aspirated,  but  will  usually  be  absorbed.  The 
danger  is  from  pleurisy,  but  if  the  air  that  entered  the 
pleura  was  clean,  and  not  infectious,  pleurisy  will  not 
sui)crvene. 

Prognosis. — If  pneumothorax  is  due  to  ulceration 
through  the  diaphragm  from  the  stomach  or  intestines, 


Pneumothorax.  193 

a  fatal  result  must  be  expected,  and  treatment  must  be 
palliative.  If  it  is  due  to  rupture  of  an  emphysematous 
lung,  serous  [)leurisy  often  does  not  occur,  for  the  air 
admitted  to  the  pleura  need  not  be  infectious.  In  such 
cases  recoveries  have  often  been  recorded.  But  rup- 
ture of  a  phthisical  cavity  will  almost  invariably  admit 
to  the  pleura  infectious  matter  and  provoke  empyema. 

Pneumothorax  is  always  a  dangerous  disease.  Death 
occurs  in  one-fourtli  of  all  cases  within  a  week  ;  in 
about  one-half  within  a  month ;  and  in  the  rest  life  may 
be  prolonged  for  a  year,  and  in  a  few  recovery  will  take 
place. 

9    I 


CHAPTER  XYII. 

Hydrothorax. 

Causes. — H3'drotlioriix  is  alwa3's  a  seconclaiy  lesion. 
It  is  a  form  of  drops}-  that  is  associated  with  general 
oedema.  Commonly  it  is  caused  by  Bright's  disease, 
heart  disease,  or  emphysema.  It  does  not  often  develop 
until  after  dropsy-  of  the  subcutaneous  tissue  and  ascites 
have  appeared.  It  is  usually  bilateral,  but  the  fluid  com- 
monly accumulates  in  one  side  to  a  greater  extent  than 
in  the  other. 

Diagnosis. — By  compressing  the  lungs  it  causes 
d3'spnoea,  and  ma}'  produce  fatal  suffocation.  The 
physical  signs  by  which  it  must  be  distinguished  are 
those  of  pleuris}'  with  effusion.  If  the  physical  signs 
are  carefull}-  noted  it  cannot  be  confounded  with  any 
other  disease.  To  differentiate  it  from  pleuris}'  ma}'  be 
difficult.  The  latter  is  rarely  bilateral,  as  the  former 
usually  is ;  the  latter  is  not  commonly  associated  with 
general  oedema  ;  there  are  no  evidences  of  inflammatory 
fever  in  the  former,  such  as  are  present  in  the  latter. 
If  the  fluid  is  withdrawn  from  the  pleural  cavity  it  will 
be  found  to  contain  the  largest  percentage  of  albumen 
when  it  is  of  inflammatory  origin.  If  its  specific  grav- 
ity is  less  than  1015,  it  is  usually  regarded  as  an  effu- 
sion ;  if  it  is  more  than  1018,  an  inflammatory  exudate. 

The  fluid  of  serous  pleurisy,  when  examined  micro- 
scopically, is  found  to  contain  blood-cells,  especially 
white  ones,  and  epithelial  cells  ;  the  fluid  of  hydrothorax 
contains  few  or  none  of  them.  The  latter  often  coagu- 
lates spontaneously  after  it  is  drawn  from  the  chest, 
and  the  former  rarely  does. 
(194) 


Hydrothorax.  195 

Treatment. — Hydrothorax  must  be  treated  by  re- 
moving its  cause.  If  the  kidneys,  skin,  and  lungs  can 
be  made  to  eliminate  water  freely  a  pleural  effusion 
ma}^  re-absorb,  as  other  dropsies  ma3'.  Often  it  threat- 
ens life,  and  immediate  relief  is  demanded.  It  can  be 
afforded  by  aspiration. 

Pr^ognosis. — Hydrothorax  usualh^  necessitates  an  un- 
favorable prognosis.  Even  if  the  fluid  is  temporarily 
removed  from  the  thorax  by  aspiration,  it  may  return, 
for  the  primar}^  disease  which  causes  it  can  seldom  be 
removed. 


SECTION  II 


Diseases  of  the  Heart. 


(197) 


DISEASES   OF  THE  PERICARDIUM, 


CHAPTER   XYIII. 

Pericarditis. 

Anatomy. — An  inflammation  of  the  pericardium  con- 
stitutes pericarditis.  The  anatomical  changes  wrought 
by  it  are  precisely  the  same  as  those  produced  by  in- 
flammation of  the  pleura.  Its  varieties  are  also  the 
same ;  there  may  be  a  dry  pericarditis,  a  serous  pericar- 
ditis, a  purulent  pericarditis,  and  chronic  pericarditis. 
Its  results  are  similar ;  it  may  undergo  resolution  ;  it 
may  produce  adhesions  and  even  obliteration  of  the 
pericardial  sack;  it  ma}^,  if  purulent,  ulcerate  through 
the  pericardium  and  thorax,  or  oftener  into  the  pleural 
cavity  or  a  bronchus,  or  througli  the  diaphragm,  or  into 
an  abdominal  viscus.  Pericardial  inflammation  may 
extend  b}^  continuity  to  neighboring  structures  and  ex- 
cite inflammation  of  the  heart-muscle,  or  pleurisy,  or 
peritonitis.  Serous  and  purulent  efl'usions  may  rapidl}' 
compress  the  heart  and  interfere  with  its  work.  Peri- 
carditis in  any  of  its  forms,  if  not  very  extensive  or 
verj'  acute,  may  not  greatl'y  disturb  the  heart's  action. 

Causes. — Pericarditis  is  rarel}'  a  primary  disease. 
The  causes  of  primary  or  idiopathic  cases  are  imper- 
fectly understood.  It  is  usuall}^  secondary  to  inflam- 
mation of  neighboring  tissues,  as  of  tlie  pleura ;  to 
acute  and  subacute  rheumatism ;  to  miliary  tuberculo- 
sis ;  to  eruptive  fevers,  and  to  p3aemia. 

Syinptoms  and  Diagnosis. — The  sj'mptoms  of  peri- 
carditis  are   often   obscured   b}^  those   of  the   primar}' 

(199) 


200  Diseases  of  the  Pericardium. 

disease.  In  the  mildest  ciises  and  in  chronic  ones  there 
ma}'  be  no  subjective  symptoms.  In  severe  cases,  and 
especiall}'  if  a  pericardial  effusion  is  considerable, 
patients  usually  appear  anxious,  cyanotic,  and  dysp- 
noeic ;  or  the  mind  will  wander,  the  delirium  some- 
times being  active  and  other  times  passive.  Stupor  and 
even  coma  ma^^  exist.  Pain  is  occasional!}'  felt  keenl}- 
in  the  cardiac  region,  but  generally  is  not  very  notice- 
able. It  ma}'  be  sharp  and  lancinating,  or  oftener  con- 
stant, and  rather  a  feeliug  of  fullnes,  of  tension,  and 
oppression  than  pain.  Tenderness  is  usually  noticeable 
over  the  heart.  Headache  is  often  associated  with  peri- 
cardial inflammation.  Occasionally  a  dry,  hacking 
cough  may  be  heard.  The  patients  usuall}'  prefer  to  lie 
with  the  head  and  shoulders  raised,  or  to  sit  upright. 
Dj'spnoea  varies  in  intensity.  It  is  usually  slight, 
except  when  a  serous  effusion  is  considerable.  The 
d3'spnoea  is  in  part  due  to  pressure  upon  the  lungs  by 
an  enlarged  pericardium,  but  is  chiefly  due  to  the  change 
in  the  heart's  action.  The  A'entricles  dilate  and  fill  im- 
perfectly. The  pressure  within  the  right  ventricle  and 
the  pulmonary  vessels  is  low,  and  the  current  through 
the  latter  is  slow.  This  is  provocative  of  d3'spnoea. 
The  same  ph3'sical  conditions  exist  in  the  left  side  of 
the  heart  and  in  the  general  circulation.  There  is, 
therefore,  a  small  and  soft  pulse.  The  heart  is  rapid, 
and,  if  much  weakened  or  irritated,  may  be  irregular. 
The  veins  about  the  neck  are  distended.  These  circula- 
tory derangements  cause  the  mental  symptoms  that. are 
sometimes  observable.  Fever  is  usually  due  to  the 
primary  disease.  It  ma}^  be  increased  b}'  pericarditis, 
or  remain  unchanged.  If  the  fever  is  due  wholly  to 
pericardial  inflammation,  it  is  found  to  follow  no  regular 
type,  and  is  not  high.     Slight  pericarditis  and  chronic 


Pericarditis.  201 

pericarditis  may  exist  without  causing  fever.  Vomiting 
and  hiccough  are  sometimes  symptoms.  They  may 
arise  from  unusual  pressure  on  the  diaphragm,  or  from 
an  involvement  of  the  vagus  nerve  in  inflammation. 
The  general  circulation  may  be  sufRcientl}^  interfered 
with  to  cause  general  oedema,  and  even  ascites  or  hydro- 
thorax.  If  death  occur,  it  ma}'  be  due  to  cerebral  con- 
gestion, oedema  of  the  lungs,  or  tlie  primary  affection. 
The  symptoms  of  recover^'  are  diminution  of  dyspnoea 
and  disappearance  of  the  characteristic  physical  signs. 
The  heart  is  usually  excitable  long  after  the  inflam- 
mation has  subsided,  or  is  quickened  by  mental  and 
physical  exertion.  The  duration  of  acute  attacks  is  ten 
dajs  or  two  weeks.  Chronic  ones  maj^  last  many  weeks 
or  months. 

A  diagnosis  is  possible,  but  must  be  made  from  the 
ph3^sical  signs.  The  prsecordia  usuall}^  appears  promi- 
nent. The  intercostal  spaces  may  even  protrude  if  the 
effusion  is  great.  The  apex  beat  is  generall}-  invisible 
if  there  is  much  effusion.  Under  the  same  circum- 
stances  it  ma}'  not  be  felt,  unless  the  patient  leans  for- 
ward or  to  the  left,  so  that  the  heart  can  gravitate 
against  the  chest-wall.  A  shifting  of  the  position  of 
the  apex  beat  is  diagnostic.  If  with  changes  in  the 
patient's  position  the  beat  moves  from  right  to  left  or 
disappears  and  re-appears  as  the  body  moves  backward 
and  forward,  it  is  evident  that  the  heart  is  swinging 
loosel}^  in  a  distended  sack.  In  the  beginning  of  peri- 
carditis, before  effusion  has  separated  the  pericardial 
surfaces,  and  in  the  fibrinous  variet}^,  a  pericardial  fric- 
tion fremitus  can  sometimes  be  felt.  Palpation  demon- 
strates tenderness  in  the  cardiac  region.  By  percussion 
the  area  of  dullness  is  found  to  be  increased  whenever 
there  is  an  appreciable  pericardial  effusion.     The  latter 

9* 


202  Diseases  of  the  Pericardium. 

first  accumulates  about  the  base  of  the  heart.  As  it 
becomes  greater  it  separates  the  heart  from  the  thorax 
and  pulmonar}'  pericardium.  The  heart  gravitates  to 
the  most  dependent  part  of  the  area.  The  shape  of  the 
normal  area  of  dullness  is  modified.  It  l)ecomes  more 
quadrilateral.  It  is  broadened  above,  and,  when  the 
effusion  is  considerable,  also  below.  When  the  effusion 
is  great  the  dull  area  ma}^  reach  the  axilla  to  the  left 
and  the  nipple  to  the  right.  Sometimes  along  the 
lateral  borders  of  the  area  of  dullness  there  is  a  semi- 
t3mpanitic  resonance,  which  is  due  to  the  compression 
and  consequent!}^  relaxed  condition  of  the  lung.  If 
when  the  patient  sits  upright  the  apex  beat  is  not  in 
the  left  lower  corner  of  the  area  of  dullness,  but  nearer 
the  median  line,  it  is  evident  the  pericardium  must  be 
distended  with  fluid.  At  the  beginning  of  acute  pericar- 
ditis friction-sounds  can  be  heard  in  almost  every  case. 
They  will  disappear  if  eflfusion  take  place  sufficient  to 
separate  the  pericardial  surfaces,  but  may  re-appear  as 
the  fluid  is  re-absorbed.  They  may  be  absent  in  chronic 
pericarditis.  The  sounds  are  usually  not  loud,  and  can 
rarely  be  heard  bej^ond  the  area  of  cardiac  dullness. 
The}^  are  often  loudest  when  the  bod}^  is  in  certain 
positions,  as  when  it  leans  forward,  or  when  deep  inha- 
lations are  drawn,  or  when  the  stethoscope  is  pressed 
against  the  chest.  Sometimes  they  are  heard  only  under 
these  circumstances,  and  are  not  constant.  Usuallj' 
they  are  hitching  in  character.  One  sound  is  heard  with 
the  contraction  of  the  auricles,  and  is  pres\'stolic ; 
another  with  the  systole,  and  a  third  with  the  ven- 
tricular expansion,  or  diastole.  The  character  of  the 
sounds  varies.  They  may  resemble  a  soft  rub,  or  be 
creaking.  They  may  be  so  loud  as  to  obscure  the  car- 
diac sounds.      Usually  the   latter  are    plainly  audible. 


Pericarditis.  203 

unless  an  effusion  makes  them  low  and  distant.  Endo- 
cardial murmurs  may  be  heard  simultaneously  with  the 
pericardial  sounds,  and  maybe  due  to  blood-states  or  to 
endocarditis. 

A  diagnosis  of  fibrinous  pericarditis  can  only  be 
made  when  pericardial  friction-sounds  are  heard.  They 
are  pathognomonic.  Endocardial  murmurs  need  not  be 
mistaken  for  pericardial,  for  they  are  blowing,  not  rub- 
bing, are  not  increased  when  the  stethoscope  is  pressed 
against  the  chest,  or  during  deep  inspiration,  and  are 
always  synchronous  with  a  given  part  of  the  heart's 
cycle.  It  is  never  difficult  to  distinguish  extra-pericar- 
dial  or  pleuro-pericardial  friction-sounds  from  them. 
Pleuritic  and  pericardial  friction-sounds  may  be  heard 
together,  both  being  produced  in  the  pleural  cavit}",  and 
they  will  cease  when  breathing  is  stopped.  The  absence 
of  subjective  symptoms,  which  may  accompany  pericar- 
ditis, will  help  to  confirm  a  decision. 

Permanent  pericardial  adhesions,  or  a  partial  or 
general  obliteration  of  the  pericardial  cavity,  may  exist 
for  3'ears.  They  ma^'  result  from  acute  or  chronic  in- 
flammation. If  the  adhesions  are  small,  they  are 
oftenest  near  the  large  cardiac  vessels.  The  heart- 
muscle  underlying  the  adhesions  is  usually  involved 
in  connective-tissue  infiltration  and  degeneration  and 
atrophy  of  the  superficial  muscle-fibres.  A  diagnosis 
of  adhesive  pericarditis,  even  when  it  is  extensive,  may 
be  impossible.  In  some  cases  the  adhesions  constrict 
the  coronary  arteries  and  interfere  with  the  heart's 
nutrition.  The  symptoms  then  are  of  heart-fatigue,  or 
exhaustion.  The  concurrence  of  two  symptoms  may  be 
considered  positive  evidence.  These  are  a  sj^stolic 
retraction  of  the  apex,  intercostal  spaces  about  it  and 
the  lower  end  of  the  sternum,  and  diastolic  collapse  of 


204  Diseases  of  the  rericardium. 

the  cervical  veins.  A  systolic  retraction  of  the  apex 
alone  may  be  produced  whenever  the  heart  cannot  be 
pushed  downward  during  systole.  Rigidit}^  of  the  arch 
of  the  aorta,  as  in  atheroma,  may  cause  it ;  aortic-valve 
stenosis  maj^ ;  and  even  sliglit  pericardial  adhesions  at 
the  base  of  the  heart  ma3\  If  the  apex  cannot  descend 
during  systole,  it  cannot  produce  the  normal  beat,  for 
the  ventricles,  when  they  contract  and  lengthen,  push 
the  apex  backward,  instead  of  forward,  and  thus  cause 
retraction.  But  if  the  retraction  is  diffuse  and  involves 
several  intercostal  spaces  and  the  lower  part  of  the 
sternum,  it  is  quite  surely  due  to  pericardial  adhesions. 
When  s3'stolic  retraction  occurs,  a  diastolic  apex-beat 
may  be  produced.  The  diastolic  projection  of  the  chest- 
wall  which  is  thus  produced  probably  favors  the  indraw- 
ing  of  the  venous  blood  by  the  heart,  and  therefore  a 
diastolic  collapse  of  the  cervical  veins.  The  diastolic 
projection  may  also  cause  a  dull  sound  to  follow  closelj^, 
and  seemingl}'  duplicate  the  diastolic  sound  of  the  heart. 
The  existence  of  pericardial  effusion  can  usually-  be 
diagnosed  directly  from  the  physical  signs  that  have 
alread}^  been  described.  The  increased  area  of  dullness 
which  it  causes  may  have  to  be  differentiated  from  (1) 
enlargement  of  the  heart,  which  is  accompanied  b}'  an 
a[)ex-beat,  in  the  lower  left  corner  of  the  dull  area,  and 
by  greater  distinctness  of  the  heart's  sounds  ;  from  (2; 
mediastinal  tumors,  aneurisms,  encysted  pleuritic  effu- 
sion, and  consolidation  of  the  borders  of  the  lungs 
adjacent  to  the  heart,  which  produce  a  greater  irregu- 
larity of  outline  of  the  dull  district  and  characteristic 
general  and  local  symptoms.  The  apex-beat  is  lacking 
in  pericardial  effusion ;  at  least,  it  is  lost  when  the 
patient  lies  upon  his  back.  It  is  also  often  absent 
when  the  heart  is  weak,  and  not  hypertrophied.     In  the 


Pericarditis.  205 

latter  case  the  cardiac  sounds  are  not  distant,  and  the 
outline  of  the  dull  area  does  not  change  with  the  position 
of  the  bod}'.  It  rany  be  absent  when  the  borders  of  the 
lungs  are  emphysematous,  but  the  area  of  cardiac  dull- 
ness is  then  small. 

The  character  of  a  pericardial  exudate  can  only  be 
told  by  aspirating  a  part  of  it.  If  pyaemia  is  the  cause 
of  pericarditis,  it  may  be  purulent.  If  rheumatism  is, 
it  probably  is  serous.  Tubercular  pericarditis  is  rarely 
primary.  It  may  be  acute  or  chronic.  The  symptoms 
in  the  following  case  will  illustrate  those  of  many  :  A 
young  man,  aged  24,  entered  Mere}'  Hospital,  after  an 
obscure  illness  of  two  weeks.  He  was  slightly  dysp- 
noeic.  His  pulse  was  feeble  and  quick.  He  often  felt 
apprehension.  At  times  he  was  nauseated.  There  was 
a  trifling  oedema  about  his  ankles.  His  temperature 
was  very  irregular,  but  never  high  (102°  F.  and  less). 
He  had  colliquative  sweats.  The  physical  signs  of  peri- 
cardial adhesions  were  plainly-  present.  At  first  no 
tubercular  lesion  could  be  found  in  the  lungs,  but  later 
they  were  involved.  Some  months  after  the  beginning 
of  this  illness  he  died  from  pulmonary  phthisis  and  car- 
diac weakness.  Several  of  his  brothers  and  sisters  are 
tuberculous  or  have  died  of  phthisis.  In  more  acute 
cases  a  suddenly  developed  cardiac  fatigue  produces  the 
existing  symptoms. 

Slight  pericarditis  often  undergoes  resolution.  It  is, 
however,  always  a  grave  disease.  Purulent  pericarditis 
is  almost  certainly  fatal. 

IVeatment. — The  indications  for  treatment  are  to 
remove  the  primary  affection  as  promptly  as  possible, 
and  in  its  earl}^  stages  to  combat  the  inflammation  b}' 
rest,  by  derivatives,  by  depletors,  and  by  opiates.  Rest 
should  be  enjoined,  at  least -so  long  as  acute  pericarditis 


206  Diseases  of  the  Pericardium. 

or  pericardial  effusions  exist.  Blisters,  cups,  and 
leeches  applied  over  the  heart  often  lessen  the  severity 
of  the  general  symptoms  which  may  arise.  A  promptly 
acting  cathartic  is  often  prescribed  as  a  depletor.  By 
these  agents  inflammatory  congestion  ma}'  be  lessened 
and  the  extension  of  inflammation  prevented.  Opiates 
are  useful  vrhen  pain  and  tenderness  are  great.  Calomel, 
in  doses  of  from  0.015  to  0.06  gramme  (^  to  1  grain), 
is  often  prescribed  to  hasten  resolution,  and  especiall}' 
the  prompt  absorption  of  serous  and  fibrinous  exudates. 
If  Iieart-fatigue  or  exhaustion  threaten,  cardiac  tonics 
and  stimulants  must  be  relied  upon  to  maintain  the 
heart's  vigor  until  rest,  nourishment,  and  the  removal 
of  tiie  cause  of  weakness  will  effect  a  permanent  restora- 
tion of  it.  Digitalis,  strophanthus,  convallaria,  caffeine, 
ammonia,  and  camphor  may  be  used.  (See  page  222.) 
To  remove  the  effusion,  blistering  plasters  may  be  ap- 
plied over  the  heart.  Often  diuretics  and  diaphoretics 
are  relied  upon.  Of  the  former,  digitalis,  strophanthus, 
potassium,  and  ammonium  acetate  are  commonly  used. 
Dry  heat  is  chiefly  employed  to  provoke  sweating,  for 
preparations  from  jaborandi  weaken  the  heart's  action. 
These  same  drugs  must  be  used  to  remove  dropsies 
which  pericarditis  ma}-  cause. 

If  cardiac  exhaustion  is  threatened  hy  an  effusion, 
it  may  be  averted  by  aspirating  the  fluid. ^  Aspiration 
gives  prompt  relief,  but  it  is  often  onl}'  temporar\',  as 
tlie  effusion  may  re-form.  The  needle  should  be  inserted 
in  the  fourth  or  fifth  intercostal  space,  close  to  the 
sternum.  If  the  liquid  is  pus,  permanent  drainage  of 
the  pericardial  cavity  should  be  established.  Recoveries 
have  occasionally  been  obtained  by  this  treatment. 
After  pericardial  adhesions  have  formed  they  cannot  be 
influenced  by  drugs. 


CHAPTER  XIX. 

Hydrops  Pericardii. 

Hydrops  pericardii  may  be  produced  under  the  same 
circumstances  as  hydrotliorax.  (See  page  194.)  Com- 
pression of  the  coronary  veins,  for  instance,  by  pericar- 
dial tubercles  or  cancerous  nodules,  may  cause  it»  It 
will  cause  the  same  symptoms  as  pericarditis  with  liquid 
effusions,  except  that  friction-sounds  will  not  at  first  be 
present.  It  can  be  distinguished  from  the  latter  by  its 
causation  and  by  the  low  specific  gravity  of  the  fluid 
(below  1015),  by  its  usual  association  with  other  drop- 
sies, and  absence  of  pericardial  tenderness.  Aspiration 
may  be  practiced,  and  even  often  repeated,  when  com- 
pression of  the  heart  threatens  its  exhaustion.  Diuret- 
ics and  diaphoretics  are  used,  as  in  other  dropsies,  to 
promote  absorption  of  the  fluid  exudate.  If  cardiac 
exhaustion  is  imminent  heart-tonics  must  be  used,  as  in 
pericarditis.  Complete  absorption  of  the  fluid  and  re- 
covery are  possible  ;  but  pericardial  dropsy  may  re-form 
after  such  absorption  if  its  cause  is  not  removable. 


(207) 


CHAPTER   XX. 

Pneumopericardium. 

Causes. — Pneumopericfirdium  may  be  caused  by  (1) 
external,  penetrating  wounds;  by  (2)  contusions  of  the 
thorax,  which  cause  the  fracture  of  a  rib,  that  in  turn 
lacerates  both  the  lung  and  pericardium;  by  (3)  ulcera- 
tion of  tubercular  or  gangrenous  pulmonarj-  cavities 
into  the  pericardium ;  by  (4)  ulceration  of  the  oesopha- 
gus or  stomach,  either  simple  or  cancerous,  Into  the 
pericardial  sack,  and  by  (5)  ulceration  of  a  purulent 
pericarditis  into  the  oesophagus,  a  bronchus,  or  the 
stomach.  By  most  of  these  processes  p3'ogenic  matter 
will  be  admitted  to  the  pericardial  cavity,  and  purulent 
inflammation,  as  well  as  pneumopericardium,  will  be  the 
result. 

Symptoms. — Subjective  sj-mptoms  which  accompau}' 
the  lesion  are  usually  as  obscure  and  as  little  character- 
istic as  in  pericarditis.  If  much  air  fill  the  pericardial 
sack,  heart-exhaustion  will  rapidly  be  produced. 

The  phj'sical  signs  are  characteristic.  On  inspection 
the  praecordia  usually  seems  prominent  and  the  inter- 
costal spaces  protrude.  The  apex-beat  is  invisible. 
Palpation  will  not  reveal  it,  unless  when  the  patient 
leans  forward  the  heart  gravitates  against  the  chest. 
Sometimes  a  friction-fremitus  can  be  felt,  or  a  peculiar 
splashing.  On  percussion-  the  area  of  cardiac  dullness 
is  replaced  by  unusual  resonance.  A  metallic  qualit}' 
is  imparted  to  the  percussion  sounds  if  a  pleximeter  is 
struck  witli  a  rod  or  metallic  bod}'.  Auscultation  re- 
veals, also,  a  metallic  qualit}'  of  the  cardiac  sounds 
which  they  do  not  normally  possess.  If  fluid  is  also  in 
(208) 


Pneumopericardium.  209 

the  pericardium,  the}'  will  only  be  heard  when  the  pa- 
tient is  recumbent.  If  friction-sounds  are  audible, 
the}^  too,  will  be  metallic  in  character.  Fluid  and  air 
both  within  the  pericardium  usuallj'^  produce,  when 
stirred  b^^  the  heart's  movements,  splashing  or  gurgling 
sounds. 

These  various  metallic  sounds,  as  well  as  areas  of 
resonance  that  in  part  displace  the  heart's  dull  area, 
may  be  produced  by  large,  superficial  cavities  in  the 
lungs  beside  the  heart,  through  which  its  sounds  are 
transmitted,  or  the}^  may  be  simulated  b}^  the  stomach 
when  it  is  greatly  distended  upward. 

Tr^eatment. — The  treatment  must  be  S3-mptomatic. 
Cardiac  tonics  are  indicated  if  heart  -  exhaustion 
threaten.  Pain  must  be  allayed  by  opiates.  If  the 
gas  within  the  pericardium  is  dangerously^  compressing 
the  heart,  it  may  be  aspirated  out.  If  purulent  inflam- 
mation occur,  drainage  should  be  established.  We  may 
attempt  to  limit  the  inflammation  by  blisters,  cups,  and 
leeches,  or  by  the  ice-bag,  as  in  simple  pericarditis. 

Prognosis. — The  prognosis  must  be  unfavorable  un- 
less the  pneumopericardium  is  caused  by  a  penetrating 
wound  of  the  thorax  which  has  not  admitted  pyogenic 
matter. 

I' 


DISEASES   OF  THE  HEART-MUSCLE, 


CHAPTER   XXI. 

Dilatation  of  the  Heart. 

Causes. — Dilatation  of  the  heart  maj'  be  secondary 
to  other  cardiac  lesions,  as,  for  instance,  valvular  ones, 
or  degeneration  of  the  muscles;  or  it  ma^'  be  secondaiy 
to  arterial  lesions  and  to  diseases  in  distant  organs. 
The  latter  are  often  called  idiopathic  cases.  The  causes 
of  dilatation  of  the  heart  are  mechanical  and  nutritive. 
Frequentl}^  both  act  together  in  a  given  case.  Of  the 
mechanical  causes  those  oftenest  acting  are  valvular 
lesions  of  the  heart ;  obstructions  to  the  aorta  by  com- 
pression or  b}^  contraction  ;  aneurisms  of  it ;  arterial 
sclerosis,  not  alone  of  the  aorta,  but  of  the  smaller 
arteries  as  well.  Obstruction  to  the  pulmonary  circula- 
tion will  provoke  dilatation  of  the  right  side  of  the 
heart.  This  may  be  caused  by  chronic  disease  of  the 
lungs,  which  destro3's  man}'  of  the  capillaries  and,  it 
ma}'  be,  some  of  the  larger  A'essels.  Pleuritic  effusions 
which  will  compress  a  lung  will  also  interfere  with  a 
perfect  pulmonar}'  circulation.  Sudden,  severe  physical 
exertion  will  occasionall}-  cause  cardiac  dilatation  ;  but 
this  M'ill  rarely  happen  unless  in  some  wa}'  the  heart's 
muscle  has  been  previously  weakened.  Most  of  these 
mechanical  causes  produce  dilatation  of  onl}-  one  of  the 
cavities  of  the  heart.     A  few  affect  it  more  extensivel}'. 

If  nutrition  has  been  imperfectl}'  maintained  in  the 
muscle  of  the  heart,  it  may  be  dilated  by  an  exertion 
which  is  not  abnormally  great.  Malnutrition  oftenest 
(210) 


Dilatation  of  the  Heart.  211 

results  from  fevers, — especially  protracted  ones, — from 
anaemias,  from  indigestions  which  cause  a  general  mal- 
nutrition, from  fatty  degeneration  and  infiltration,  and 
from  obstructions  to  the  coronar^^  circulation. 

Anatomy. — Dilatation  of  one  ventricle  only  ma}' 
occur,  as  when  there  is  aortic-valvular  insufficiency;  or 
both  sides  may  be  distended,  as  in  mitral  insufficienc3\ 
Usuall}^  dilatation  and  h3'pertrophy  co-exist,  but  the 
ventricular  walls  may  be  thin.  Often  the  heart  is  pale 
from  degeneration  of  its  muscle.  Venous  hyperaemia 
mny  exist  in  many  organs  if  the  dilatation  has  been 
chronic  or  great. 

Symptoms. — A  diagnosis  can  onl}^  be  made  from  the 
physical  signs  which  dilatation  of  the  heart  produces. 
In  man}'  cases  there  are  no  subjective  s3^mptoms  that 
can  be  ascribed  to  the  heart-lesion,  although  there  ma}' 
be  others  that  are  due  to  a  primary  affection. 

If  there  is  no  hypertrophy  of  the  heart  accompany- 
ing the  dilatation,  the  apex-beat  will  be  invisible,  or  it 
will  be  feeble  and  diffuse.  It  is  displaced  more  or  less 
to  the  left.  On  palpation  the  heart's  beat  can  usually 
be  felt,  even  when  it  is  invisible.  If  much  hypertrophy 
accompany  the  dilatation,  the  apex-beat  may  appear 
strong  and  feel  lifting  and  energetic;  but  the  pulse  will 
be  small,  soft,  and  quick.  Irregularity  of  the  heart  is 
often  due  to  dilatation. 

Percussion  will  demonstrate  an  increased  area  of 
cardiac  dullness.  The  directions  in  which  this  increase 
is  greatest  will  depend  upon  whether  a  single  cavity  of 
the  heart  or  several  are  involved.  Auscultation  will 
reveal  feeble  cardiac  sounds.  Tlie  first  sound  will  lose 
much  of  its  booming  character  and  resemble  closely  the 
second.  Even  when  valvular  lesions  do  not  exist  sys- 
tolic murmurs  may  be  heard.     This  will  rarely  happen 


212  Diseases  of  the  Heart- Muscle. 

except  when  dilatation  is  associated  with  anaemia.  If 
hj'pertrophy  is  co-existing  the  sounds  may  be  booming, 
and  even  stronger  than  natural.  We  can,  then,  conclude 
that  dilatation  exists  only  because  there  are  evidences 
of  heart-exhaustion,  and  we  know  that  where  they  exist 
with  hypertrophy  dilatation  does  also.  With  valvular 
lesions  we  know  that  dilatation  and  hypertroph}^  are 
alwa3's  associated. 

Subjective  symptoms  ma}-  exist,  although  commonh- 
the}'  are  wanting.  If  the  dilatation  is  great  the  usual 
s^-mptoms  of  cardinc  exhaustion  will  be  present.  They 
result  chiefly  from  an  imperfect  balance  of  the  venous 
and  arterial  blood.  The  arteries  grow  small  and  the 
veins  dilate;  passive  engorgement,  therefore,  develops. 
Dyspnoea,  enlargement  of  the  liver  and  spleen,  the  symp- 
toms of  renal  engorgement,  or  general  dropsy  ma\'  exist 
alone  or  in  combination. 

In  mild  cases,  and  especially  if  the  dilatation  accom- 
pany an  excitable  nervous  sj'stem,  the  quick  beating 
of  the  heart  ma}^  be  felt,  as  palpitation.  A  beat  ma}^ 
drop  or  be  delayed,  and  ma}'  then  cause  anxiet}'  or 
fright.  Frequent  and  uncontrollable  sighing  so  often 
accompanies  dilatntion  of  the  heart  that  I  always  search 
for  the  latter  when  I  observe  the  former.  Tlie  sis^hinor 
is  undoubtedl}'  due  to  an  unsteady  enervation  of  the 
respiratory  muscles  ;  it  ma}'  also  be  caused  by  mental 
depression  or  flatulent  indigestion.  Not  un frequently 
one  of  these  latter  conditions  accompanies  cardiac  dila- 
tation. A  lack  of  energy  and  endurance  characterizes 
all  cases  of  cardiac  dilatation,  unless  compensating 
hypertrophy  co-exists. 

Treatment. — The  object  of  treatment  is  to  cause  con- 
traction of  the  heart  or  compensating  hypertropy  of  its 
muscle.     Strength    may  be   temporarily  given   by  the 


Dilatation  of  the  Heart.  213 

drugs  that  increase  the  force  of  the  systole,  such  as 
digitalis,  strophanthus,  and  convallaria.  It  can  be  per- 
manentl}'  mnintained  only  when  an}'  degeneration  of 
muscle-fibres  that  may  exist  undergoes  resolution,  and 
when  with  suitable  tonics,  foods,  and  exercise  they  are 
invigorated.  The  tonics  which  will  stimulate  the  cardiac 
tissues  to  a  better  degree  of  nutrition  are  strychnia, 
caffeine,  quinia,  and  iron.  They  are  indicated  not  only 
when  anseniia  exists,  but  also  when  muscular  degenera- 
tion does.  The}^  may  be  best  given  combined  with 
digitalis  or  its  congeners. 

If  it  is  a  moderate  dihitation  arising  from  a  pro- 
tracted fever  tliat  must  be  dealt  with,  sponging  the 
skin  and  baths  with  tepid  or  cold  wat^*  stimulate  the 
circulation  and  aid  in  maintaining  a  vigorous  action  of 
the  henrt  which  will  prevent  dilatation. 

If  the  heart  is  dilating,  liquids  must  not  be  drunk  in 
quantities  sufficient  to  augment  the  blood.  This  is 
especially  true  if  there  is  drops}'  or  anaemia.  Then  a 
reduction  of  the  bulk  of  the  blood  will  prove  advanta- 
geous. (See  page  224.)  Food  must  be  nutritious  and 
not  difficult  to  digest.  Martin  has  shown  that  alcohol 
will  cause  dilatation  of  the  heart.  Such  beverages  cer- 
tainly predispose  to  it  by  leading  to  tissue  degeneration 
and  to  loss  of  vascular  and  cardiac  tone.  They  should 
be  excluded  from  the  dietary  of  those  suffering  from 
this  disease. 

If  moderate  exercise  is  steadily  persevered  in  it 
will  lead  to  a  better  nutrition,  and,  it  may  be,  to  hyper- 
trophy of  the  heart's  muscle.  If  it  is  violent,  it  may 
strain  the  muscles  by  unduly  increasing  the  blood- 
pressure,  and  thus  augment  the  dilatation. 

Antipyretics  diminish  tissue-change  and  interfere 
with  nutrition.     Their   frequent    or    prolonged   use   is 


214  Diseases  of  the  He  art- Muscle. 

contra-indicated  whenever  degeneration  exists  and  we 
wish  to  prevent  its  spread.  Aconite,  venitrnni,  nnd 
other  drugs  that  cause  vascular  and  cardiac  relaxation 
are  contra-indicated. 

Prognosis. — The  prognosis  of  cardiac  dilatation  will 
depend  entirel}'  upon  the  possibilit}'  of  removing  its 
cause.  Mechanical  causes  usually  cannot  be  removed. 
If  the  obstruction  which  the}^  cause  to  the  circulation 
can  be  overcome  by  hypertrophy,  they  will  not  endanger 
life.  Dilatation  from  a  w^eakness  of  the  muscular  fibres 
of  the  heart,  because  of  their  malnutrition,  can  generally 
be  perfectly  overcome.  If  degeneration  is  extensive  or 
its  cause  cannot  be  removed,  a  favorable  result  is 
impossible.  Weak  muscles,  because  of  haemorrhage, 
acute  or  subacute  anaemia,  indigestion,  or  fever,  is 
curable  ;  but  if  it  is  due  to  chronic  Bright's  disease  or 
to  obstruction  to  the  coronary  arteries,  it  is  incurable. 


CHAPTER  XXII. 

Cardiac  Hypertrophy. 

Anatomy. — "When  the  heart's  muscle  hj^pertrophies, 
the  number  of  fibres  ma^^  increase  or  they  maj^  enlarge. 
Usually,  both  these  changes  occur  simultaneousl}^  Hy- 
pertroph}'  may  enlarge  the  entire  heart,  or  a  part  of  it. 
A  few  of  the  muscular  papilUi^  onl}'  may  enlarge,  or  the 
right  or  left  ventricle,  oi'both.  The  auricles  are  capable 
of  very  limited  hypertroph}'.  The  cavities  of  the  heart 
are  usually  dilated  when  tlie  walls  In^pertrophy,  but  may 
remain  normal,  or,  in  extremel}^  rare  cases,  be  contracted. 
The  interstitial  tissues  sometimes  increase.  If,  in  spite 
of  the  hypertroph}',  the  heart  is  continuous!}-  fatigued,  it 
may  undergo  fatty  degeneration.  Hj'pertrophy  causes 
the  heart's  wall  to  appear  thick,  and  to  be  unusually 
firm  and  hard.  It  is  usually  normal  in  color,  but  may 
be  a  brownish  red,  from  an  excess  of  i)igment  in  it. 

Causes. — Hypertroph}'  is  the  result  of  prolonged 
overexertion.  This  ma^-  be  due  to  obstruction  to  the 
circulation,  which  must  be  overcome,  or  to  unusual  and 
prolonged  muscular  work,  and  rare!}-  to  nervous  excite- 
ment and  strain.  Obstructions  ma}-  exist  within  the 
heart  at  its  valvular  orifices, — for  example,  in  chronic 
valvular  disease, — or  outside  the  heart,  as  in  stenosis  or 
compression  of  the  aorta  or  small  arterioles.  Endar- 
teritis obliterans  often  obstructs  the  arterioles  exten- 
sivel}-,  as  in  the  kidne3's  in  chronic  interstitial  nephritis. 
Aneurisms  of  the  aorta  or  its  main  branches  cause 
additional  work  for  the  left  ventricle,  and  provoke  it  to 
hypertroph}-.      Permanent    pericardial    adhesions    fre- 

(215) 


216  Diseases  of  the  Heart-Muscle. 

quentlj-  lead  to  hypertrophy.  Acute  and  chronic 
parench^'matous  nephritis  are  sometimes  accompanied 
b^^  cardiac  hypertrophy.  It  cannot  always  be  due  to 
vascuh^r  obstruction  in  these  cases,  for  the  latter  does 
not  always  exist.  It  is  probablj^  sometimes  due  to  a 
chemical  cardiac  irritant  which  is  in  the  blood. 

Symptoms. — H3'pertroph3'  of  the  heart  is  usually  a 
secondary  lesion.  Subjective  sj-mptoms  that  accompany 
it  are  due  to  the  primar}^  affections.  Occasionalh^  per- 
sistent hard  beating  of  the  heart  is  felt,  and  especially 
during  left  decubitus.  But  one  must  depend  upon 
physical  signs  in  order  to  make  a  diagnosis.  The  prae- 
cordia  is  unusualh'  prominent.  Particularh'  is  this  true 
in  the  earlier  years  of  life.  The  apex-beat  will  be  seen 
to  the  left  of  the  nipple,  and  lower  than  is  normal.  The 
beat  moves  a  larger  area  of  the  chest-wall  than  is  usual, 
and  it  is  more  powerful  and  lifting.  Palpation  confirms 
its  location,  its  diffusion,  and  its  strength.  If  the  left 
ventricle  only  is  lijqDertrophied,  its  anterior  surface  will 
press  against  the  thoracic  wall,  and  the  right  ventricle 
will  be  rolled  backward.  The  apex-beat  will  then  be 
produced  b}'  the  left  ventricle.  If  the  right  ventricle 
is  chiefly  or  exclusively  hypertrophied,  pulsation  may 
be  seen  and  felt  to  the  right  of  the  sternum,  and  will, 
in  almost  ever}-  case,  be  easily'  demonstrable  just  beneath 
it.  This  is  due  to  the  contact  of  the  right  ventricle 
with  the  thoracic  wall,  for  when  it  hypertrophies  the 
left  is  displaced  backward,  and  the  right  ventricle 
chiefly  forms  the  anterior  surface  of  the  heart.  Per- 
cussion demonstrates  an  enlargement  of  the  area  of 
cardiac  dullness.  If  the  left  side  of  the  heart  is  exclu- 
sively involved,  it  will  be  increased  to  the  left;  if  the 
right  side,  to  the  right ;  and  if  both  sides,  in  each  direc- 
tion.    It  may  extend  an  inch  or  more  to  the  left  of  the 


Cardiac  Hyper tj-ophy.  217 

nipple,  and  tlie  same  to  the  right  of  tlie  sternum.  The 
cardiac  sounds  are  usually  normal.  The  first  sound  at 
the  apex  ma^'  be  louder  and  more  booming.  If  the  left 
ventricle  is  hypertrophied,  the  second  sound  over  the 
aorta  is  accentuated.  If  the  right  ventricle  is  hyper- 
trophied, it  is  the  second  sound  over  the  pulmonarj^ 
arter}'  that  is  accentuated.  Tiiese  accentuations  aie  due 
to  increased  tension  of  the  respective  semilunar  valves. 
If  both  sides  of  the  heart  are  thickened,  we  find  a  com- 
bination of  the  signs  just  described,  and  especinlly 
evidence  of  cardiac  enlargement,  both  to  the  right  and 
left.  The  cardiac  sounds  can  often  be  plainly  heard  at 
a  considerable  distance  from  the  heart.  The  carotids 
often  pulsate  visibly,  and  sometimes  a  systolic  murmur 
can  be  heard  in  them  which  is  due  to  the  unusual  ten- 
sion of  the  vessel's  wall  and  its  consequent  irregular 
vibrations.     The  pulse  will  be  large  and  firm. 

If  the  cause  of  the  heart's  increased  work  cannot  be 
removed,  or  at  least  compensated  for,  the  heart  will 
become  fatigued,  in  spite  of  its  hypertroph}'.  It  will 
grow  rapid  in  action,  or  irregular.  The  lungs  will 
become  congested,  and  d3'spno?a  will  develop.  The 
liver  will  enlarge.  The  legs  ma}-  become  oedematous. 
The  urine  will  diminish  in  quantity  and  may  grow 
cloudy  and  contain  albumen.  Dropsy  of  the  abdominal 
cavit}'  or  other  serous  sacs  may  be  produced.  The 
pulse  will  be  soft,  of  medium  or  small  size,  in  spite  of 
the  strong  throb  of  the  heart  against  the  chest.  Death 
may  be  caused  by  oedema  of  the  lungs  or  heart- 
exhaustion. 

Moderate  hypertrophies  which  are  produced  by 
causes  that  are  remoTable  may  disappear  when  their 
cause  is  gone. 

Hypertrophy  is  a  conservative  process.     It  is  favor- 

10    K 


218  Diseases  of  the  Heart-Muscle. 

able  to  life.  It  ma}-  enable  the  heart  to  overcome,  per- 
fectl}'  and  with  ease,  a  permanent  obstruction  to  the 
circulation.  XJnfortunatel}',  often  the  obstruction  grad- 
uallj^  increases,  and  finalh'  cannot  be  compensated  for 
b}^  hypertroph}'.  Then  the  symptoms  of  cardiac  ex- 
haustion develop. 

Treatment. — No  treatment  is  indicated  if  hypertro- 
phy compensates  for  an  existing  obstruction  to  the 
blood's  flow ;  but  after  compensation  has  been  obtained 
the  heart  must  not  be  wearied  b}'  additional  and  unnec- 
essary labor.  Therefore,  fatiguing  exercise  must  be 
avoided.  Constipation  and  slow  or  labored  digestion 
will  impede  the  circulation  and  involve  the  heart  in 
extra  labor.  They  must  be  prevented  or  i)romptly 
cured.  The  diet  should  be  simple  and  nutritious. 
Stimulants  and  tea,  coffee,  and  tobacco  must  be 
avoided.  Milk,  eggs,  lean  meat,  simple  vegetables,  and 
wholesome  fruit  may  be  used.  Greasy,  fat,  and  very 
farinaceous  foods  must  be  used  sparingh',  or  not  at  all. 
Sufficient  exercise  in  the  fresh  air  should  be  taken  to 
maintain  a  good  oxygenation  of  the  blood  and  a  fair 
degree  of  muscular  vigor,  but  it  should  never  be  ex- 
hausting or  violent. 

The  nitrites  are  sometimes  used  (see  page  228.)  when 
high  arterial  tension  is  the  cause  of  h3'pertroph3'.  They 
will  lessen  it,  and  thereby  reduce  the  heart's  labor.  Digi- 
talis is  contra-indicated  so  long  as  the  heart  beats  slowly 
and  steadily.  If  it  is  often  or  persistenth'  quick  or 
irregular,  it  ma}^  be  used.  Strophanthus  is  to  be  pre- 
ferred because,  in  usual  doses,  it  does  not  cause  so  much 
arterial  contraction,  and,  therefore,  as  high  arterial  ten- 
sion. The  former  gives  the  heart  more  worlv  to  do. 
After  the  heart  has  In'pertrophied,  and  tlien  grows 
rapid  or  irregular  in  action,  we  may  feel  sure  that  dila- 


Cardiac  Hypei'trophy .  219 

tation  is  forming  or  increasing,  and,  usuall}^,  that  fatty 
degeneration  is  established.  The  treatment  must  then 
be  adapted  to  combat  these  lesions.  Cardiac  exhaustion 
is  tlie  cause  of  death  when  the  heart  is  hypertrophied. 
Its  prevention  is,  therefore,  the  indication  for  treatment. 


CHAPTER  XXIII. 

Fatty  Heart. 

Anatomy. — Two  lesions  are  named  fatty  heart.  They 
are  technicall}'  named  fatt}'  infiltration  and  fatty  degen- 
eration. In  fatty  infiltration  the  connective  tissue  be- 
neath the  pericardium,  and  especiall}'  about  the  coronar}" 
vessels,  is  filled  with  I'at.  The  entire  heart  ma}'  be 
thickly  enveloped  in  it.  Fnt  may  also  accumulate  be- 
tween the  muscle-fibres  in  the  fibrous  frame-work  of  the 
organ.  The  muscular  fibres  may  atropli}'  and  become 
very  small.  Such  an  accumulation  of  fat  and  concomi- 
tant muscular  atroph}'  interfere  with  a  vigorous  action 
of  the  heart.  As  the  lesion  is  almost  limited  to  obese 
people,  the  cardiac  fatigue  which  often  co-exists  with 
it  is  partly  due  to  tlie  larger  volume  of  fluid  that 
must  be  moved  through  their  more  numerous  capillary 
vessels. 

Fatty  degeneration  is  due  to  a  malnutrition  of  the 
cardiac  muscle  wliicli  ma>'  lead  to  its  disorganization. 
In  the  muscle-fibres  appear  minute  granules,  that  often 
obscure  their  striated  sti'ucture.  If  the  malnutrition  is 
suflflcientl}'  great,  the  outline  of  the  fibre  is  lost.  A 
crowd  of  granules  represent  it  for  a  time,  but  soon 
they  are  absorbed.  Thus,  disintegration  and  disappear- 
ance of  tissue  may  grow  out  of  the  degeneiation.  The 
muscles  that  are  aflfected  are  alwavs  weakened.  They 
show  this  b}'  a  lack  of  endunince,  as  Avell  as  by  a  feeble- 
ness of  contraction.  The  entire  heart  and  many  other 
organs  and  tissues  may  l)e  simultaneously  aflfected  in 
this  way;  but  usuallj'  only  a  patch  of  muscle-fibres  here 
and  there  is  involved.  The  muscular  papillae  and  the 
(220) 


Fatty  Heart.  221 

fibres  beneath  the  endocardium  are  especially  apt  to  be. 
The  inside  of  the  A^entricle  often  appears  mottled  with 
3^ellowish  spots.  When  the  entire  heart  is  degenerated 
it  will  all  look  yellowish-red  and  greasy.  It  will  be 
soft.  If  a  knife  is  drawn  across  the  cut  surface  of  de- 
generated muscle-fibres,  droplets  of  oil  can  be  seen  in 
the  fluid  that  gathers  on  it.  Cloudy  swelling  may 
precede  fatty  degeneration,  or  be  associated  with  it. 

Symptoms  and  Causes. — A  positive  diagnosis  of  fatt}^ 
heart  is  difficult  to  make,  and  is  often  impossible.  Fatt}^ 
infiltration  may  be  suspected  in  persons  who  are  obese 
and  whose  heart's  action  is  feeble.  The  thick  chest- 
wall  may  make  it  impossible  to  say  whether  the  heart  is 
enlarged  or  not,  or  to  judge  of  its  strength  by  the  apex- 
beat,  for  the  latter  often  cannot  be  felt.  But  if  the 
heart  is  weak  it  will  beat  fast,  even  from  moderate  phys- 
ical exertion.  Its  first  sound  will  be  short,  and  valvu- 
lar in  character.  The  pulse  will  be  small  and  soft.  If 
the  heart  is  much  enfeebled,  the  cervical  veins  may  be 
distended.  Shortness  of  breath  is  partly  due  to  the 
cardiac  weakness,  and  largely  to  the  obesity  of  the 
chest.  A  feeling  of  oppression  is  often  experienced, 
and  sighs  for  breath,  which  are  unsatisfying,  are  invol- 
untarily drawn.  Little  endurance  is  possessed.  A 
disinclination  for  ph38ical  exertion  is  usual. 

Much  fatty  infiltration  or  fatt}-  degeneration  may 
exist  and  be  unaccompanied  by  symptoms.  Sponta- 
neous rupture  of  the  heart  has  been  known  to  occur 
suddenly,  because  of  the  weakness  of  its  walls.  In  other 
cases  the  symptoms  of  heart-exhaustion  may  develop, 
such  as  chronic  venous  hyper.'iemia  and  oedema  of  various 
organs;  or  angina  pectoris  may  develop.  A  slow  pulse, 
psendo-apoplectic  attacks,  and  Cheyne-Stokes  respira- 
tion, if  they  occur  together  in  the  same  person,  are  quite 


222  Diseases  of  the  HeaiH-Mascle. 

characteristic  of  fattj'  heart.  Unfortunately,  they  rarely 
occur  together,  and  either  S3'mptom  alone  is  not  charac- 
teristic. The  pulse  niaj^  be  ver}'  slow, — even  less  than 
twenty  beats  to  the  minute.  This  is  not,  however,  usual, 
for  oftener  it  is  quickened,  at  least,  b}^  bodily  exertion. 
The  arcus  senilis  frequently  develops  in  those  in  whom 
fatty  degeneration  exists  extensivelj',  or  results  from 
local  anaemias  that,  in  turn,  are  caused  hy  arterial 
stenosis.  The  presence  of  some  of  the  causes  of  fatty 
degeneration  aid  one  to  make  a  diagnosis.  Prolonged 
anaemias  are  especiall}^  apt  to  produce  such  degenera- 
tion. Chlorosis,  leukaemia,  and  pernicious  anaemia  are 
examples  of  the  forms  oftenest  leading  to  it.  Chronic 
or  protracted  fevers  will  also  cause  it.  Valvular  lesions 
or  arterial  obstructions  which  cannot  be  compensated 
for  by  h3'pertroph3^  are  common  causes.  Coronary 
sclerosis,  by  producing  local  cardiac  anaemias,  ma}^  lead 
to  it.  Phosphorus  poisoning  will  cause  intense  general 
fatty  degeneration.  Chronic  tobacco  and  alcoholic 
poisoning  may  lead  to  similar  results.  Obesit}'  and 
fatty  infiltration  of  the  heart-muscle  ma}'  be  an  inherit- 
ance;  oftenest  it  is  due  to  a  lack  of  vigorous  exercise 
and  an  excess  of  fat-producing  foods. 

Treatment. — If  the  heart  beats  feebl}^  and  is  excit- 
able, because  of  fatt}'  degeneration,  cardiac  and  general 
tonics  are  indicated.  Aniiemia  requires  iron.  This  drug- 
also  seems  to  prevent  degeneration.  Such  general 
tonics  as  strychnia  and  quinia  will  invigorate  nutrition. 
Such  cardiac  tonics  as  digitalis,  strophanthus,  and 
caffeine  are  required  to  temporarily  strengthen  its  beats 
and  restore  the  equilibrium  of  the  venous  and  arterial 
currents.  Strophanthus  is  preferable  to  digitalis  in 
these  cases,  for  it  contracts  the  peripheral  vessels  less 
and  increases  the  arterial  tension  less.     Catfeine  seems 


Fatty  Heart.  223 

not  only  to  stimulate  the  heart,  but  to  increase  its  abil- 
ity to  appropriate  nutriment.  A  combination  like  the 
following  will  often  prove  promptly  efficacious  : — 

R  Ferri  citratis,        .         .     grms.  12.0  (gr.  ij). 

CafFein.  citratis,  .         .     grms.  15.0  (gr.  iiss). 

Pulveris  strophanthi,  .     grm.     0.015  or  0.02  (gr.  \  or  ^). 
Sig. :  To  be  given  iu  a  capsule  every  four  hours. 

It  is  especially  adapted  to  the  stage  in  which  palpi- 
tation is  easily  provoked.  As  the  heart  grows  stronger, 
strophanthus  or  digitalis  may  graduall}^  be  omitted  and 
strychnia  or  quinia  substituted.  It  must  be  remem- 
bered of  powdered  strophanthus  that  it  is  laxative. 
Such  treatment  must  be  persisted  in  for  weeks,  and 
often  for  months.  Inhalations  of  oxj^gen  have  been 
recommended,  as  a  lack  of  it  is  supposed  to  cause  degen- 
eration. But  we  have  no  evidence  that  the  blood  will 
take  up  more  oxygen  if  it  is  breathed  pure  than  when 
diluted,  as  in  common  air.  Respiratory  gymnastics 
vsee  page  151),  which  will  insure  frequent  empt3ings  of 
the  lungs  and  their  complete  expansion  with  fresh  air, 
will  accomplish  quite  as  much  as  ox3'gen  inhalations. 
To  maintain  good  nutrition  of  the  heart  good  nutrition 
must  be  maintained  everywhere.  A  perfect  lymph- 
circulation  is  essential  for  this,  and  can  only  be  assured 
by  general  exercise.  Exercise  should  be  gentle,  but 
should  be  as  long  continued  as  is  possible  Avithout  pro- 
ducing a  feeling  of  excessive  fatigue  or  exhaustion.  It 
should  not  be  violent. 

To  diminish  the  amount  of  fat  which  may  infiltrate 
the  heart's  muscle  in  obese  persons,  Oertel's  treatment 
is  the  best.  It  aims  to  lessen  the  bulk  of  fluid  in  the 
vessels  and  the  addition  of  fat,  and  to  strengthen  the 
heart  by  exercise.     If  the  quantity  of  blood  and  fatty 


224  Diseases  of  the  Heart-Muscle. 

tissue  is  lessened,  the  amount  of  work  which  the  heart 
has  to  do,  in  moving  the  fluid  through  the  adipose  tissue, 
is  diminished.  Copious  sweatings  will  relieve  the  system 
of  its  excess  of  liquid,  but  to  prevent  its  prompt  resto- 
ration its  ingestion  must  be  limited  and  carefully  pre- 
scribed. Sweating  may  be  produced  etfectively  by 
Turkish  baths,  or  by  vigorous  and  prolonged  exercise. 
To  prevent  the  continued  accumulation  of  fat,  carbo- 
h^'drates  must  be  eaten  very  sparingly.  If  an  albuminous 
diet  is  adhered  to,  the  fat  already  stored  in  the  body 
will  be  utilized  as  carbohydrate  food.  This  is  especiall}' 
true  if  exercise  is  taken  freely,  so  that  tissue-changes 
are  kept  vigorous.  Exercise  will  provoke  sweating,  will 
maintain  a  vigorous  circulation,  necessitate  deep  and 
frequent  breathing,  thorough  blood  ox3'genation,  and 
active  tissue-change;  it  will  strengthen  voluntarj^ 
muscles  and  cause  them,  and  with  them  the  heart,  to 
hypertroph3\  Exercise  should,  if  possible,  be  continued 
for  several  hours  daih',  b3'  those  who  need  this  treat- 
ment. It  should  gradually  be  increased.  Oertel  recom- 
mends mountain-climljing  more  than  any  other  form. 
In  level  countries,  rapid  walking,  and,  later,  as  strength 
and  endurance  increase,  running  may  be  substituted  for 
climbing.  It  should  be  sufficientl}'  active  to  provoke 
some  shortness  of  breath  and  increased  rapiditj'  of  the 
heart's  action.  If  these  symptoms  begin  to  cause  dis- 
tress, a  few  moments'  rest  should  be  enjoined.  The 
amount  of  exercise  that  should  be  taken  by  an  individual 
will  depend  upon  its  effects.  Therefore,  each  patient 
must  be  closely  watched  and  guided.  Too  violent  exer- 
tion might  permanentl}^  and  dangerously  injure  the 
heart,  which  is  already  injured  and  fatigued. 

When  the  quantity  of  fluid  that  is  to  be  ingested 
must  be  prescribed,  it  is  best  to  ascertain  about  how 


Fatty  Heart.  225 

often  and  how  much  the  patient  habitually  takes,  and  at 
first  lessen  the  amount  rather  than  the  frequency  of  its 
use.  So  it  is  best  to  learn  what  his  usual  diet  is,  and 
then  eliminate  from  it  the  greater  part  of  the  carbo- 
hydrates. 

Alcoholics  should  be  excluded  from  the  diet  of  those 
who  have  fatt}-  heart.  They  make  tissue-change  slow 
by  lessening  the  oxygen-carrying  power  of  the  blood. 
The}'  lessen  the  vigor  of  nutritive  changes  partly  in  the 
same  way,  and  by  expanding  the  peripheral  vessels  and 
slowing  the  peripheral  blood-current.  Tlie  weaker 
preparations,  such  as  beer,  are  taken  in  such  amounts  as 
also  to  greatly  augment  the  fluid  within  the  bod}-. 

If  the  heart  is  exhausted  and  can  be  spurred  onl}- 
temporarily,  the  symptoms  of  passive  engorgement  and 
oedema  of  various  tissues  will  be  little  affected,  and, 
sooner  or  later,  in  spite  of  these  drugs,  the  pulse  will 
grow  smaller  and  quicker.  As  the  symptoms  of  ex- 
haustion intensify,  diffusible  stimulants  like  ammonia 
and  camphor  are  employed  advantageousl}-.  (See  page 
101.) 

To  relieve  the  oedema  which  may  accompany'  fatty 
heart,  such  as  anasarca,  ascites,  pleural  and  pericardial 
dropsy,  the  alkaline  diuretics  and  more  or  less  drastic 
cathartics  (see  page  292)  can  be  used  in  addition  to  car- 
diac tonics.  The  serous  cavities  may  have  to  be  aspi- 
rated or  punctured  to  effect  immediate  relief. 

10* 


CHAPTER  XXIY. 

Indurative  Degeneration. 
Anatomy. — By  indurative  degenei'fition  I  mean  a 
lesion  that  is  primarily  a  degeneration,  and  secondarily 
an  li3'perplasia,  of  connective  tissue  which  causes  indu- 
ration. It  results  from  a  gradually  produced  and  per- 
sistent local  anaemia  within  the  heart.  Sclerosis,  throm- 
bosis, or  embolism  of  some  branches  of  the  coronary 
arteries  are  its  usual  causes.  In  the  anaemic  area  there 
is  first  degeneration  and  atroph}-  of  the  muscle-fibres, 
because  of  diminished  nutriment  and  a  lessened  vitality'.. 
Under  conditions  of  nutrition,  in  which  highh'  special- 
ized structures,  such  as  muscle-fibres,  cannot  live,  the 
connective  tissues  grow.  This  is  possibly  nature's 
method  of  attempting  to  repair  the  weakened  fabric.  If 
a  heart  in  which  induration  and  necrosis  has  devel- 
oped is  examined,  there  will  be  found  imbedded  in  the 
muscle,  and  usually  near  the  apex,  a  patch  of  gray, 
fibrous  tissue.  "Tlie  heart's  wall  may  or  ma}'  not  be 
very  thin  at  this  point.  The  patch  may  be  minute,  or 
the  size  of  a  half-dollar.  While  oftenest  in  the  ven- 
tricular wall,  and  near  the  apex,  it  ma}'  be  an^'where  in 
the  heart's  substance.  It  ma}'  be  deeply  imbedded  in 
the  muscle  or  near  its  surf^ice.  It  may  involve  only  a 
small  part  of  the  heart's  wall  or  its  entire  thickness. 

Under  the  microscope  the  indurated  tissue  shows  its 
connective-tissue  character.  If  the  patch  is  still  grow- 
ing, about  its  margins  the  cells  composing  it  will  be 
embryonic  in  type,  and  will  infiltrate  the  neighboring 
muscle-fibres,  which  will  be  granular  and  atrophied. 
The  result  of  these  anatomical  changes  is  always  the 
(226) 


Indurative  Degeneration,  22t 

production  of  a  Imrcl,  cicatrix-like  structure.  But  tli(3 
loss  of  muscle-fibres  makes  the  wall  of  the  heart  weak  and 
tlie  connective  tissue  cannot  compensate  for  the  loss. 
Rupture  of  the  heart  through  the  indurated  tissue  may 
occur,  or,  if  the  latter  is  just  beneath  the  endocardium, 
and  roughens  it,  a  cardiac  thrombus  may  form,  which, 
in  turn,  may  produce  emboli.  Cardiac  aneurism  is  a 
third  occasional  result  of  this  lesion.  At  the  point  of 
weakness  the  heart's  wall  will  bulge  and  form  a  thin- 
walled  sac  containing  blood.  Such  aneurisms  may  be 
the  causes  of  thrombosis,  because  of  the  slow  blood- 
stream within  them,  or  they  may  rupture. 

Symptoms. — Indurative  degeneration  may  exist  and 
produce  no  symptoms.  In  some  cases  the  only  symp- 
toms are  those  of  cardiac  fatigue  or  exhaustion.  The 
group  of  symptoms  named  angina  pectoris  are  common 
accompaniers  of  this  lesion.  Unfortunately,  they  may 
also  occur  with  fatty  degeneration  of  tlie  heart,  with 
coronar}'  sclerosis  without  indurative  degeneration, 
with  aortic  valvular  lesions,  and  aortic  aneurism. 
But  though  this  is  true,  angina  pectoris  is  always  sug- 
gestive of  coronary  sclerosis,  and  the  latter  of  indura- 
tive degeneration.  If  with  angina  pectoris  we  find 
evidence  of  sclerosis  of  radial  or  temporal  or  other 
arteries,  we  may  feel  quite  sure  of  coronary  sclerosis. 

Angina  pectoris  implies,  when  it  is  severe,  an 
agonizing  pain  of  oppression  in  the  chest,  about  the 
sternum,  accompanied  by  radiating  pains  to  the  left 
breast  and  shoulder,  and  into  the  left  arm.  The  suf- 
ferer's face  expresses  pain,  and  even  fear.  The  skin  is 
pale,  cold,  and  often  clammy.  The  pulse  is  small,  hard, 
and  quick.  The  heart-beats  are  rapid,  feeble,  and  often 
irregular.  More  rareh^  they  are  diffuse  and  vigorous, 
though  the  pulse  is  weak  or  irregular.     Respiration  is 


228  Diseases  of  the  Heart-Muscle. 

oppressed,  irregular,  sighing  and  unsatisfying,  but  not 
dyspnoeic.  Death  from  heart-failure  may  occur  in  the 
midst  of  such  an  attack.  Usuallj'  the  onset  is  not 
sudden,  but,  from  a  feeling  of  discomfort  during  two  or 
three  hours,  an  agonizing  pain  develops.  It  may  last  a 
few  moments  or  for  hours.  When  it  subsides,  vomiting 
not  unfrequently  occurs.  When  the  pain  is  gone,  as  a 
rule,  great  prostration  remains.  The  pulse  gradually 
orows  full  and  slow,  and  often  is  irreo^ular  and  excited 
b}'  slight  physical  or  mental  exertion.  The  attacks 
may  recur  frequently, — at  least,  ever}'  da}'  or  two, — or 
at  long  intervals  of  months  or  years,  or  not  at  all.  They 
ma}'  be  of  all  grades  of  severity,  from  slight,  almost 
momentary,  attacks  of  heart  anguish  to  those  of  intense 
severity. 

It  is  evident,  however,  that  during  life  a  positive 
diagnosis  of  indurative  degeneration  is  impossible,  for 
neither  the  symptoms  of  cardiac  fatigue  nor  angina 
pectoris  are  pathognomonic  of  it.  If  angina  pectoris 
and  arterial  sclerosis  co-exist,  we  may  conclude  that  the 
former  is  due  to  coronary  sclerosis,  and  we  know  that 
this  may  lead  to  indurative  degeneration.  In  rare  cases 
angina  pectoris  occurs  when  no  lesion  of  the  circulatory 
apparatus  is  demonstrable. 

Treatment. — Treatment  must  be  symptomatic.  If 
there  is  cardiac  fatigue  or  exhaustion,  it  must  be  treated 
as  in  other  diseases.  (See  page  222.)  Angina  pectoris 
may  be  relieved  by  morphine,  or  chloroform,  or  ether; 
but  these  drugs  must  be  used  with  great  caution,  as  they 
are  liable  to  produce  functional  derangements  of  the 
nervous  system.  The  nitrites  are  equally  efficacious  in 
certain  cases,  especially  in  those  in  which  there  is  an 
arterial  spasm.  Amyl  nitrite  may  be  given  by  inhala- 
tion with  wonderfully  prompt  effects.     The  cold,  gray 


Indurative  Degene7'ation.  229 

skin  of  the  face  soon  grows  flushed  and  warm,  the  head 
feels  full,  and  the  agonizing  breast-pain  lessens.  Nitro- 
glycerin is  equally  beneficial  in  the  same  cases,  but  little 
less  promptly  so.  It  may  be  given  in  doses  of  1  or  2 
drops  of  a  1-per-cent.  solution,  and  may  be  repeated 
every  three  or  four  hours.  The  nitrite  of  soda  ma}'  also 
be  used,  in  doses  of  0.06  to  0.12  gramme  (1  to  2  grains) 
of  the  pure  drug,  or  0.3  to  0.45  gramme  (5  to  8  grains) 
of  the  preparation  usualh^  dispensed. 

While  the  i)atient  is  cold  he  should  be  made  warm 
with  hot  flasks  and  his  skin  chafed.  To  avoid  returns 
of  the  attacks,  tiie  patient  should  eschew  excitement  or 
undue  bodily  exertion, — should  in  no  way  produce  high 
arterial  tension  by  arterial  contraction,  as  may  be  done 
by  constipation  or  indigestion. 

Such  hygiene  as  will  promote  good  nutrition,  active 
tissue-oxidation,  and  healthful  muscular  vigor  will  help 
to  prevent  these  attacks  when  a  degenerating  or  en- 
feebled heart  causes  them. 


CHAPTER   XXY. 

Myocarditis. 

Anatomy.  —  Indurative  degeneration  has  been  by 
many  regarded  as  of  inflammatory  origin.  But  inflam- 
mation in  the  lieart-muscle  is  due  to  extension  from 
neighboring  tissue  or  to  septic  infection.  It  commonly 
results  from  a  peri-  or  endo-  carditis  which  deeply  in- 
volves the  heart-wall.  Inflammation  may  produce  thick- 
ening of  these  thin  tissues  and  destruction  of  the 
superficial  muscular  fibres  by  causing  their  atroph}^  or 
degeneration  when  the^'  are  separated  by  round-cells, 
which  ultimately  are  transformed  into  fibrous  tissue. 
In  these  ways  an  indurated  area  or  scar  may  be  pro- 
duced which  will  resemble  indurative  degeneration. 

Purulent  myocarditis  is  produced  by  septic  emboli. 
Ulcerative  endocarditis  and  pyaemia  are  oftenest  the 
cause  of  them.  They  alwaj's  produce  abscesses.  This 
form  of  myocarditis  is  rare.  The  abscesses  are  usually 
small.     There  may  be  several  of  them,  or  only  one. 

Symptoms. — There  are  no  distinguishing  s3'mptoms. 
Myocarditis,  which  grows  out  of  peri-  or  endo-  carditis, 
produces  no  other  svmptoms  than  those  of  the  primary 
disease.  The  scars  which  may  result  from  it  will  pro- 
duce no  symi)toms,  or  they  may  be  accompanied  b}'  the 
various  ones  associated  with  indurative  degeneration. 
Purulent  myocarditis  can  rarely  be  diagnosed. 

Treatment. — The  treatment  of  mj'ocarditis  does  not 
differ  from  endo-  and  peri-  carditis  in  the  first  group  of 
cases  or  from  p^'semia  in  the  other. 

(230) 


DISEASES  OF  THE  ENDOCARDimL 


CHAPTER  XXYI. 

Endocarditis. 

Anatomy. — Inflammation  of  the  lining  of  the  heart  is 
a  common  cardiac  affection.  Any  part  of  the  interior 
of  the  heart  may  be  inflamed,  but  commonly  only  the 
valves  or  their  immediate  neighborhood  is  involved. 
Acute  endocarditia  is  almost  invariably  limited  to  those 
portions  of  the  valves  which  chafe  against  each  other. 
After  birth  it  rarely  affects  the  right  side  of  the  heart, 
though  it  commonl}^  does  before. 

When  acutely  inflamed  the  point  of  attack  is  at  first 
reddened.  The  subendothelial  tissues  are  soon  infil- 
trated with  serum  and  round-cells.  If  the  valves  are 
aflfected,  the}^  are  thus  thickened.  The  endothelial  cells 
loosen,  and  are  detached.  The  raw  surface  is  now 
coated  with  a  thin,  opaque  film,  which  ma}'  grow,  b}^ 
deposition  of  fibrin,  into  a  wart-like  protuberance  as 
large  as  a  pin-head,  or  even  a  bean.  These  protuber- 
ances are  grayish,  or  yellowish,  or  reddish  yellow  in 
color.     The}'  are  often  brittle  ;  brej^k,  and  form  emboli. 

Two  forms  of  acute  endocarditis  exist :  The  first  is 
known  as  septic^  malignant^  or  ulcerative  ;  the  second  as 
non-malignant^  simple^  or  verrucose.  The  former  is  due 
to  septic  infection.  Micro-organisms  abound  in  the 
lesions,  and  produce,  when  carried  elsewhere  in  emboli, 
septic  infection  of  distant  organs.  Septic  endocarditis 
is  so  uniformly  characterized  by  loss  of  substance  in  the 

(231) 


282  Diseases  of  the  Endocardium. 

valves  that  it  is  often  iiuined  ulcerative.  Similar  loss  of 
substance  may  occur,  but  seldom  does,  in  simple  endo- 
carditis. In  ulcerative  endocarditis,  if  the  valvular 
vegetations  are  detached,  a  loss  of  substance,  with  ragged 
and  sharpl3^-cut  edges,  is  laid  bare.  This  ulcerating 
destruction  of  the  tissues  maj^  extend  deepl}',  and  may 
even  penetrate  a  valve.  Oftener,  where  the  valve  is  thus 
thinned  the  endothelium  upon  its  opposite  surface  be- 
comes distended  and  protrudes.  Slowly,  it  will  be 
stretched  out  into  a  sac,  with  a  narrow  neck  at  the 
point  of  ulceration.  Such  a  sac  is  known  as  a  valvular 
aneurism.  It  may  contain  fluid  blood  or  a  thrombus. 
An  aneurism  may  rupture,  or  even  a  thin  valve  that  is 
not  aneurismal  ma3\ 

In  simple  endocarditis  there  is  oftenest  built  up  on 
the  abraded  valvular  surface  a  vegetation,  the  base  of 
which  is  composed  of  round  or  granulation  cells  and  the 
upper  part  of  fibrin.  Under  the  microscope  the  upper- 
most cells  in  these  vegetations  are  degenerated  and 
granular.  In  the  deepest  layers  of  fibrin  a  few  atrophied 
nuclei  ma}'  still  be  seen,  which  have  been  set  free  from 
cells  that  have  disintegrated. 

Chronic  inflammation  may  begin  as  such  or  grow 
out  of  acute  inflammation.  It  is  characterized  b}'  thick- 
ening of  the  valves,  roughening  of  their  surfaces,  rigidity, 
contraction  and  contortion  of  them,  often  degeneration 
of  their  deeper  tissue,  and  even  calcification.  The  valves 
may  become  partly  adherent  to  one  another,  or  to  neigh- 
boring parts  of  the  endocardium.  The  fibrillse  and  mus- 
cular papillie  ma}'  be  involved,  both  in  acute  and  chronic 
changes.  They  may  be  broken,  or  shortened,  or  con- 
torted, and  thus,  also,  interfere  with  the  function  of  the 
valves.  If  chronic  endocarditis  arise  by  extension  of 
endarteritis,  the  base  of  the  aortic  valves  may  be  chiefly 


Endocarditis.  233 

involved  instead  of  the  edges,  or  the  upper  instead  of  the 
lower  surface.  When  the  inflammation  spreads  from  the 
mitral  to  the  aortic  valves,  or  vice  versd^  the  base  is 
also  especiall}^  apt  to  be  atfected. 

Instead  of  lapsing  into  chronic  inflammation  or 
leaving  a  chronic  valvular  lesion,  acute  endocarditis  ma^^ 
undergo  perfect  resolution.  This  is  rare,  however. 
These  various  changes  in  the  valves  modiiy  their  func- 
tion. Their  swelling,  causes  rigidit}^  Chronic  tliicken- 
ings  and  calcifications  make  them  still  more  rigid.  Yer- 
rucosities  or  chronic  roughness  will  prevent  perfect 
coaptation  of  the  edges  of  the  valves  Contraction  of 
them  will  prevent  a  perfect  closure  of  the  orifice,  which 
they  should  guard.  Their  roughness,  their  slow  move- 
ment, and  other  changes  will  cause  unusual  eddies  and 
currents  in  the  blood-stream,  which  produce  the  modified 
heart-sounds  that  are  recognized  as  murmurs. 

The  imperfect  opening  or  closing  of  a  cardiac  orifice 
by  tlie  valves  will  produce  other  changes  in  the  heart 
and  circulation.  We  can  best  describe  these  later.  (See 
page  240). 

Emboli  originating  in  the  heart  may  cause  abscesses, 
if  they  are  septic;  or  infarcts,  or  dropsy,  or  local 
anaemia,  if  they  are  aseptic. 

Gause.i. — It  has  been  proven  that  septic  endocarditis 
oftenest  arises  as  a  complication  of  puerperal  fever  or 
of  some  other  form  of  sepsis.  As  the  point  of  infec- 
tion cannot  ahva^'s  be  discovered,  some  cases  are 
described  as  idiopathic  or  primar3\  Several  diff'erent 
forms  of  micro-organisms  have  been  found  in  the  car- 
diac lesions.  It  seems  quite  well  established  that  the 
disease  has  not  a  single  specific  microbic  cause.  Old 
valvular  and  cardiac  lesions  are  especiall}'  the  locus  of 
septic  endocarditis.     After  puerperal  fever,  septic  endo- 


234  Diseases  of  the  Endocardium* 

carditis  oftenest  complicates  articular  rheumatism,  infec- 
tious exanthemata,  diphtheria,  typhoid,  periostitis,  and 
osteomyelitis. 

Simple  endocarditis  is  rarel}^,  if  ever,  a  primary  affec- 
tion. It  usually  complicates  articular  rheumatism.  It 
is  associated  both  with  the  mildest  and  the  severest 
cases  and  with  subacute  and  acute.  It  is  said  to  occur 
oftenest  in  those  cases  in  which  many  joints  are  simul- 
taneously involved.  Gonorrhoial  and  other  rheumatoid 
affections  are  rarely  accompanied  by  endocarditis. 
Chorea  is  ver^^  frequently'  associated  with  it.  The 
exanthemata,  protracted  fevers,  nephritis,  pleurisy, 
pneumonia,  phthisis  pulmonum,  and  many  other  dis- 
eases may  be  complicated  by  it.  The  tubercle  bacillus 
has  been  found  in  endocardial  vegetations  which  devel- 
oped in  a  consumptive.  Oftenest  the  valves  become 
irregularh'  slightly  thickened  and  roughened  in  phthisis, 
but  not  sufficientl}'  modified  to  cause  cardiac  symptoms. 

Chronic  endocarditis  frequentl}'  grows  out  of  acute 
attacks,  but  in  man}-  cases  its  origin  is  insidious.  Senile 
changes  which  produce  sclerosis  in  the  blood-vessels 
lead  to  chronic  valvular  and  endocardial  thickenings  and 
induration.  Severe  and  unusual  muscular  strain  also 
disposes  to  the  disease,  as  military  surgeons  have  demon- 
strated among  recruits.  It  often  follows  nephritis, 
diabetes,  gout,  S3'philis,  chronic  lead  and  alcohol  poison- 
ing. Certain  irritants  in  the  blood  undoubtedl}'  produce 
it  in  these  affections. 

Symptoms. — It  is  impossible  to  describe  a  group  of 
symptoms  which  characterize  all  cases  of  acute  septic 
endocarditis,  for  no  two  are  precisel}^  alike.  Many 
cases  cannot  be  diagnosed,  and  many  more  not  without 
weeks  of  observation  and  study.  The  course  of  the 
temperature    and    many    of    the    sj-mptoms    commonly 


Endocarditis,  235 

resemble  either  t3^plioid  or  intermittent  fever.  But  the 
cardiac  disease  is  often  unnoticed  in  the  course  of  a 
primary  affection,  such  as  puerperal  fever  or  some  other 
septicaemia.  Those  cases  which  most  resemble  typhoid 
have  a  fever  of  a  continuous  type.  The  patients  are 
apathetic.  The  tongue  is  dry  and  brown  ;  the  pulse  is 
quick,  soft,  and  dicrotic  ;  the  abdomen  tympanitic,  and 
sometimes  roseola  spots  can  be  found  on  it.  Other 
cases  not  only  resemble  intermittent  fever  in  the  course 
of  their  temperature,  but,  as  in  them,  the  spleen  en- 
larges ;  a  chill,  fever,  and  sweat  recur  with  uniformity 
each  day,  or  each  second  or  third  day.  If  the  disease 
runs  a  long  course  the  fever  gradually  becomes  more 
continuous  and  less  intermittent,  or  less  regularly  so. 
In  both  groups  of  cases  there  may  be  ph3'sical  signs  of 
a  cardiac  disease,  or  they  may  be  entirely  wanting.  The 
occurrence  of  embolism  is  most  suggestive  of  a  cardiac 
lesion.  Emboli  ma}'  cause  hemorrhagic  infjircts,  or 
cedema,  paralj'sis,  or  often  abscesses.  If  they  are  very 
minute,  and  especiall}'  if  the}'  are  in  internal  organs, 
tliey  may  not  manifest  themselves.  Embolism  of  the 
skin  and  retina  can  be  observed  more  readily.  If  the 
physical  signs  of  a  valvular  lesion  gradually  develop,  a 
diagnosis  may  be  made  with  some  positiveness.  A 
gradual,  but  progressive,  loss  of  flesh  and  strength  takes 
place.     Death  is  almost  inevitable. 

Acute  non-malignant  endocarditis  can  usually  be 
diagnosed  with  certainty.  If  the  lesion  is  not  upon  the 
valves,  or  if  it  does  not  interfere  with  their  action,  a 
diagnosis  is  impossible.  Reliance  must  be  placed  en- 
tirely upon  the  physical  signs,  for  subjective  S3mptonis 
may  be  wanting  or  indefinite.  In  rheumatism  and 
chorea  the  heart  should  be  frequentl}^  examined,  as 
valvular   lesions   may   otherwise   be    overlooked.      The 


23fi  Diseases  of  the  Endocardium. 

temperature  imxy  be  raised  or  remain  unchanged  when 
the  heart  is  iuA^olved.  Sometimes  oppression  is  simul- 
taneously felt  in  the  cardiac  region  ;  more  rarel}',  pain 
and  tenderness  are  there.  Palpitation  or  irregularity 
of  the  heart  first  attracts  attention  to  other  cases.  Sj'n- 
cope  and  d3'spnoea  are  rare;  if  they  occur,  they  are 
usually  due  to  heart-clot  or  embolism.  Ofteuer  no  sub- 
jective symptom  suggests  a  cardiac  lesion,  but  it  is 
discovered  b}'  the  development  of  physical  signs.  Em- 
bolism and  its  effects  will  often  make  positive  a  diagnosis 
that  otherwise  is  probable. 

If  in  the  course  of  a  disease  that  is  likelv  to  be  com- 
plicated b}'  endocarditis  murmurs  arise,  we  are  justified 
in  suspecting  its  existence  and  often  in  affirming  it.  If 
diastolic  murmurs  develop  under  these  circumstances, 
we  are  assured  that  endocarditis  has  produced  the  con- 
ditions which  give  rise  to  the  murmur;  but,  unfortu- 
nately, diastolic  murmurs  are  not  the  commonest. 
SN'stolic  murmurs  may  develop  in  fevers  or  when  there 
is  anaemia,  even  though  no  endocarditis  exists.  Though, 
as  a  rule,  endocarditis  is  the  cause  of  systolic  murmurs 
which  accompany  acute  articular  rheumatism,  I  am  sure 
that  in  several  cases  I  have  heard  a  mitral  systolic 
murmur  which  was  not  due  to  this  cause.  In  these 
cases  the  murmurs  disappeared  entirely  when  the  pa- 
tient regained  strength  and  his  blood  its  richness.  If, 
however,  such  murmurs  persist,  and  if,  subsequently, 
changes  in  the  size  and  shape  of  the  heart  develop, 
which  are  usual  when  the  valves  are  permanently  modi- 
fied, we  may  make  a  positive  diagnosis.  If  embolism 
occur,  a  diagnosis  can  be  made  with  greater  certainty. 

While  it  is  impossible  always  to  make  a  diagnosis 
of  acute  endocarditis  when  it  exists,  and  especially  of 
the  maliijnant  form  of  the  disease,  a  diagnosis  is  usuallv 


Endocarditis.  23T 

possible.  The  symptoms  of  most  value  are  those  which 
a  physical  examination  demonstrate  or  which  arise  from 
embolism,  and  the  co-existence  of  one  of  the  diseases 
that  are  commonly  regarded  as  causative.  The  physical 
signs  which  make  it  possible  to  determine  which  valve 
is  chiefly  affected  are  the  same  that  enable  us  to  make 
the  same  determination  in  chronic  valvular  disease. 
(See  pages  243  to  250.) 

Treatment. — The  treatment  of  ulcerative  endocarditis 
must  be  directed  to  the  conservation  of  strength.  Gen- 
eral nutrition  must  be  maintained  bv  administering 
food  as  it  would  be  to  those  suffering  from  continued, 
intermittent,  or  septic  fever.  Milk,  gruels,  broths,  and 
eggs  should  constitute  the  regimen.  If  the  stomach  is 
not  retentive,  or  if  its  digestive  powers  are  impaired, 
food  is  best  given  frequentl}^,  in  small  amounts,  but  to 
others  it  may  be  given  more  generoush^  and  less  fre- 
quently. 

Cardiac  exhaustion  and  failure  are  commonly  the 
immediate  cause  of  death.  As  the  lieart  grows  feeble, 
it  must  be  spurred  to  greater  efforts  by  digitalis,  stro- 
phanthus,  convallaria,  and  similar  drugs.  When  it  is 
extremel}'  feeble,  diffusible  stimulants,  such  as  ammo- 
nium carbonate  and  camphor,  must  be  relied  upon.  A 
great  number  of  antiseptics  have  been  administered  in 
these  cases,  but  unavailingly. 

As  non-malignant  endocarditis  is  a  secondary  affec- 
tion, treatment  must  be  addressed  to  the  primary  disease. 

In  the  onset  of  the  endocardial  inflammation  an  ice- 
bag  may  be  constantl}^  applied  to  the  prnecordia,  or, 
instead,  blisters,  followed  by  fomentations,  may  be  used. 
They  will  act  as  they  do  when  serous  sacs  are  inflamed. 
The  mild  chloride  of  mercury  is  used  as  in  pleurisy'  and 
pericarditis,  with  the  hope  that  it  will  modif}^  the  exu- 


238  Diseases  of  the  Endocardium. 

date  and  prevent  its  organization.  In  subacute  and 
non-chronic  cases  tlie  iodide  of  soda  or  potash  is  used. 
Digitalis  or  analogous  remedies  must  be  employed  if  the 
heart  is  undul}^  weak,  irregular,  or  fast.  During  conva- 
lescence they  can  be  gradually  omitted,  and  bitter  tonics 
and  iron  can  be  adVantageousl}-  used  to  restore  the 
heart-muscle  to  a  greater  degree  of  nutritial  vigor.  In 
these  cases,  too,  nourishment  must  be  carefully  admin- 
istered, so  as  to  maintain  strength. 

Prognosis. — In  malignant  endocarditis  the  prognosis 
is  unfavorable ;  in  non-malignant  cases  it  must  be 
guarded,  for,  almost  without  exception,  a  chronic  val- 
vular lesion  is  produced.  If  this  does  not  interfere  so 
greatly  with  the  function  of  the  valves  that  the  heart 
fails  by  hypertrophy  to  compensate  for  it,  life  ma}^  not 
be  shortened.  In  such  cases  there  is  a  physiological, 
though  not  an  anatomical,  recovery.  But,  in  many 
cases,  either  the  lesion  is  too  great  to  be  compensated 
for  or  the  general  vigor  of  the  individual  is  not  sufficient 
to  make  hypertrophy  possible. 


CHAPTER  XXYII. 

Chronic  Yalvular  Disease. 

Nature  and  Anatomy. — Anatomical  deformity  of  a 
cardiac  valve  may  exist  without  disturbing  its  function. 
For  example,  a  scar  upon  a  valve  may  make  it  abnormal, 
but  it  may  still  open  and  close  perfectly  the  orifice  it 
guards.  No  cardiac  disease  is  produced  by  such  a 
lesion.  If  a  valve  is  so  displaced  or  deformed  that  it 
narrows  the  orifice  it  should  protect,  or  leaves  it  con- 
stantly open,  its  function  is  not  performed,  and  a  more 
or  less  extensive  change  in  tlie  heart,  and  usually  in 
other  organs,  will  be  produced. 

The  valves  may  be  unusuallj^  thickened  and  rough- 
ened b}'  inflammation,  by  degeneration  and  calcification, 
or,  infrequentl}',  hy  new  growths.  The}'  may  be  con- 
torted by  scars  ;  the}'  may  be  adherent  to  one  another, 
or  to  the  adjoining  wall  of  the  heart ;  they  may  be  torn  ; 
they  may  be  perforated  by  an  ulcer  or  ruptured  aneu- 
rism. Their  functional  activity  may  be  interfered  with 
b}^  rupture,  contraction,  or  degeneration  of  the  muscular 
papillae  or  chordae  tendinse.  A  valvular  orifice  may  be 
dilated  and  the  valves  made  incompetent  though  the}^ 
are  not  diseased.  Some  of  these  lesions  ma}^  be  devel- 
oped congenitally, — either  from  imperfect  development 
of  the  foetus,  or  from  inflammation  or  other  less  frequent 
and  imperfectl}^  understood  causes.  When  lesions  are 
congenital  thej'  are  usually  upon  the  right  side  of  the 
heart.  In  adults  the}^  are  commonly  due  to  endocar- 
ditis ;  degenerative  changes,  such  as  produce  arterial 
atheroma,  also  produce  some  of  them.  A  valve  is  rarely 
ruptured  from  strain  alone.     But  usuallj^,  as  in  a  case 

(239) 


240  Disease fi  of  the  Endocardium. 

that  recently  came  under  m}'  own  observation,  a  severe 
bodily  strain  increases  the  arterial  blood-pressure,  and 
causes  a  rent  in  the  edge  of,  for  example,  an  aortic  valve 
that  hns  been  slightlj'  weakened  b}-  degeneration — which 
may  be  extensive — in  the  aorta.  Occasionally,  when  the 
cardiac  cavities  dilate,  the  orifices  are  also  stretched,  so 
that  valvular  incompetency  results.  Tumors  are  A'ery 
rare  within  the  heart.  Sometimes  foreign  bodies,  espe- 
ciall}'  cardiac  thrombi,  entangled  in  the  chordae  tendinse 
and  protruding  through  a  cardiac  orifice,  will  produce 
S3'mptoms  that  precisely  simulate  a  valvular  lesion. 

Symptoms. — The  general  symptoms  which  accompan}* 
a  chronic  valvular  lesion  are  due  to  cardiac  weakness, 
and  are  the  same  as  those  accompanying  cardiac  weak- 
ness from  other  causes.  If  the  heart,  by  hypertroph}', 
can  compensate  for  the  stenosis  or  insufficiency  which  a 
chronic  valvular  lesion  ma}'  cause,  general  symptoms 
will  not  arise.  These  symptoms  are  due  to  a  disturb- 
ance of  the  balance  between  the  arterial  nnd  venous 
circulations.  The  arteries  are  imperfectly  filled  ;  the 
blood  within  flows  slowly,  under  diminished  pressure. 
The  veins  are  overfilled,  but  in  them,  too,  the  Jjlood- 
stream  is  slow ;  tiie  pulse,  therefore,  feels  soft,  and  is 
small  or  of  medium  size.  The  heart  is  quick  when  com- 
pensation is  not  perfect,  and  often  becomes  irregular 
and  tumultuous.  Physical  exertjon,  mental  excitement, 
or  difficult  digestion  will  frequently  hasten  the  heart's 
action  to  a  distressing  degree.  Stenosis  causes  this 
imperfect  vascular  balance  by  making  the  arterial  stream 
slow,  b}'  filling  the  arteries  slowly-  and  iraperfecth',  and, 
consequently,  making  pressure  within  them  low.  Be- 
hind the  point  of  stenosis  the  pressure  is  increased  and 
the  veins  are  overfilled.  Insufficiency  produces  the 
same  results,  because  of  the  regurgitation,  which  also 


Chronic  Valvular  Disease.  241 

ciiuses  overfilling  and  increased  tension  in  the  veins,  and 
imperfect  filling  and  low  tension  in  the  arteries. 

The  imperfect  vascnhir  balance  leads  to  passive 
engorgement  of  various  organs.  The  lungs  and  bronchi 
are  commonlj'  thus  afl[*ected.  The}'  may  undergo  the 
changes  which  are  chnracteristic  of  passive  hypersemia, 
and  that  are  known  as  brown  induration.  Often,  when 
congested,  the  bronchi  become  inflamed,  and  remain 
persistently  so,  with  varving  degrees  of  severity.  Dysp- 
noea is  a  common  symptom,  and  may  be  due  to  the 
congestion,  to  bronchitis,  to  brown  induration,  to  oedema 
of  the  lung,  or  to  pleural  drops}'. 

The  liver  may  be  greatly  enlarged  from  venous 
hyperaemia.  It  can  then  be  felt  as  a  smooth  body  with 
rounded  borders.  It  may  be  so  large  that  the  lower 
ribs  will  be  pushed  outward.  It  is  usually  subject  to 
frequent  and  very  marked  variations  in  size.  It  is  ten- 
der, and  its  distension  often  causes  i)ersistent  soreness. 
If  the  hyperaemia  has  lasted  long,  the.  liver  may  gradu- 
ally contract  and  its  surface  ma}'  grow  rough ;  it  will 
then  become  hard.  Thus,  it  is  transformed  into  the 
condition  known  as  the  nutmeg-liver.  Often  an  icteric 
hue  can  now  be  observed  in  the  patient's  skin. 

The  kidneys  are  also  liable  to  somewhat  similar 
changes.  By  congestion  albuminuria  may  be  caused. 
The  urine  becomes  moderately  diminished  in  qnantit}'. 
Its  specific  gravity  is  from  1025  to  1035.  It  is  usually 
turbid,  and  deeper  colored  than  natural.  The  amount 
of  albumen  present  is  not  great.  Hyaline  and  granular 
casts  can  be  found  in  the  sediment,  but  are  not  numer- 
ous. Blood-cells  are  also  often  present  in  small  num- 
bers. In  this  stage  of  congestion  acute  inflammation 
may  occur  ;  if  prolonged,  congestion  leads  to  contraction 
and  cirrhosis.     The  urine  will  then  increase  in  amount; 

11   L 


242  Diseases  of  the  Endocardium. 

its  specilic  gnivit}'  will  fall  below  normal ;  the  albumen 
will  be  redaced  to  a  trace,  and  casts  will  be  rarely 
found. 

Passive  h^'persemia  of  the  stomach  and  intestines 
leads  to  slow  digestion,  constipation,  and,  finall}',  often 
to  catarrhal  inflammation.  These  lesions  produce  cor- 
responding symptoms  :  indigestion,  anorexia,  vomiting, 
flatulence,  and  constipation  ma}' characterize  one  case; 
sour  stomach,  p3'rosis,  tenderness,  or  diarrhoea  another. 
Anasarca  and  dropsy  of  au}^  of  the  serous  cavities  ma^- 
also  result  from  the  imperfect  balance  of  the  arterial  and 
venous  circuhition. 

All  of  these  lesions  and  symptoms  do  not  ordinarily 
occur  in  the  same  case,  but  the}'  occur  in  varying  com- 
binations. Oftenest  a  congestive  dyspnoea  and  general 
anasarca  are  combined.  I  have  seen  cases  in  Mdiich  the 
liver  was  enormousl}-  enlarged  by  congestion  while  the 
lungs  were  almost  unaffected,  though  respiration  was 
uncomfortable,  because  the  liver  impeded  the  move- 
ments of  the  diaphragm.  Indigestion  also  increased  tlie 
patient's  distress,  but  there  was  no  anasarca.  In  other 
cases  the  kidneys  may  be  early  involved. 

Bodily  temperature  is  not  changed  in  these  cases, 
unless  inflammation  causes  it  to  rise.  A  slow  and  im- 
perfectl}'  maintained  circulation  leads  to  slow  and  imper- 
fect tissue-change.  Reparative  processes  are  retarded. 
Perfect  nutrition  is  not  maintained.  The  disturbances 
of  the  pulmonar\',  gastric,  hepatic,  and  renal  functions 
contribute  to  malnutrition.  The  muscles  grow  small 
and  weak.  The  blood  becomes  impoverished,  and,  there- 
fore, the  face  is  often  sallow  or  anaemic.  The  patient 
feels  languid  and  lacks  endurance.  If  dyspnoea  is  con- 
siderable, voluntar}'  exercise  may  be  inhibited.  If 
anasarca  is  extensive,  locomotion  may  be  impossible. 


Chronic  Valvular  Disease.  243 

A  diagnosis  must  be  based  upon  the  local  or  cardiac 
symptoms.  The  existence  of  a  cardiac  murmur,  of  en- 
largement of  the  heart,  and  cardiac  exhaustion  are  not 
sufficient  to  make  certain  the  existence  of  a  chronic 
valvular  disease.  I  have  seen  pericarditis  and  peri- 
cardial calcification  produce  these  symptoms,  which 
gradually  developed  and  lasted  for  several  3ears.  I 
have  known  muscular  degeneration  to  cause  similar 
symptoms.  It  is  true  that  under  these  circumstances 
tiie  murmur  is  always  S3^stolic,  and  is  usually  best  heard 
Mt  the  heart's  apex.  To  establish  a  diagnosis,  we  must 
find  a  cause  for  a  chronic  lesion,  and  we  must  find,  on 
physical  exnmination,  the  comhination  of  changes  which 
are  the  result  of  valvular  lesions. 

Aortic  insufficiency  will  cause  great  dilatation  of  the 
left  ventricle,  and,  if  the  lesion  is  chronic,  hypertroph}' 
also;  for  the  ventricle  must  hold  not  only  its  norniMl 
quantum  of  blood,  but  also  what  flows  back  into  it 
through  the  patent  valves  during  diastole.  The  other 
cardiac  cavities  may  not  be  changed.  These  lesions 
cause  the  prsecordia  to  be  prominent.  The  ap,ex-beat  is 
readih'  seen  and  felt.  It  is  diffuse.  It  is  to  the  left  of 
the  nipple,  and  usually  a  little  lower  than  is  normal.  In 
the  slipra-sternal  notch  pulsations  can  often  be  seen. 
The  carotid  pulse  is  usunlly  visible,  and  sometimes  a 
capillary  pulse  can  be  demonstrated  beneath  the  finger- 
nails by  the  varying  breadth  of  the  color-zone  with  each 
heart-beat.  Pulsation  in  the  retinnl  arteries  can  also 
sometimes  be  seen.  Palpation  confirms  the  diflfusion  of 
the  apex-beat,  and  demonstrates  its  powerful  lifting 
character.  This  unusual  forcefulness  is  due  to  hyper- 
troph}'.  In  many  cases  a  diastolic  fremitus  can  be  felt 
at  the  base  of  the  heart.  Percussion  demonstrates  the 
cardiac  enlargement.     The  left  border  of  dullness  will 


244  Diaeasea  of  the  Endocardium. 

extend  to  the  left  of  the  nipple,  and  sometimes  even  to 
the  tinterioi"  Jixillary  line.  The  area  of  dullness  usually 
begins  a  little  higher  than  natural.  Rarel}^  it  extends 
a  little  to  the  right  of  the  sternum,  in  the  second  inter- 
costal space;  this  is  due  to  dilatation  of  the  aorta.  The 
right  border  of  the  heart  remains  unchanged,  except  in 
rare  cases,  when  it  is  found  farther  to  the  right  than  is 
natural,  and  a  substernal  beating  and  accentuation  of  the 
pulmonar^^  second  sound  indicate  a  dilatation  and  113'per- 
tropli}'  of  the  right  ventricle.  The  cause  of  these 
changes  is  usually  obscure.  It  maybe  due  to  stretching 
the  mitral  orifice,  and  consequent  insufficienc}-  of  the 
mitral  valves. 

A  diastolic  murmur  characterizes  aortic  insutlicienc}'. 
It  is  generall}'  best  heard  about  the  centre  of  the  ster- 
num. This  Is  because  the  murmur  is  produced  not  at 
the  aortic  valves  or  in  the  aorta,  but  in  the  upper  part 
of  the  left  ventricle,  where  the  blood  from  the  auricle 
and  the  blood  flowing  back  from  the  aorta  commingle 
and  produce  the  eddies  which  cause  the  murmur.  Often 
the  second  aortic  sound  is  obliterated  hy  the  murmur, 
but  not  always.  If  some  of  the  aortic  leaflets  can  un- 
fold naturall}'  the}'  may  produce  the  second  sound.  In 
other  cases  a  second  sound  ma}'  be  transmitted  from 
the  pulmonar}'  arterj^  The  murmur  is  usually  heard 
oyer  the  pulmonary  artery,  but  not  so  loud  and  clear  as 
farther  to  the  right.  At  the  apex  there  usually  is  no 
murmur,  and  both  first  and  second  sounds  are  normal. 
Occasionally^,  a  diastolic  murmur  is  faintly  heard  there, 
and  more  rarel}'  a  systolic  one.  The  latter  is  not  always 
significant  of  aortic  stenosis.  Wlien  it  exists  a  satisfac- 
torj^  explanation  of  its  causation  is  difficult.  It  maybe 
due  to  irregular  contraction  of  tiie  heart-muscles. 

In  the  carotid  a  systolic  murmur  is  often  heard.     It 


Chronic  Valvular  Disease.  245 

is  sometimes  propagated  from  the  valve ;  sometimes  it 
is  due  to  irregular  vibrations  of  the  vessels,  which  arise 
from  their  excessive  tension  ;  or,  it  is  of  heemic  origin. 
At  times  the  signs  of  aortic  insufficiency'  disappear. 
This  may  be  due  to  the  stretching  of  one  valvular  cur- 
tain so  that  the  valvular  leakage  is  stopped,  or  vegeta- 
tions ma}'  grow  so  that  the}^  can  help  to  close  the 
orifice.  Occasionall}^,  an  insufficienc}'  is  gradually  con- 
verted into  a  stenosis. 

-  The  pulse  is  usually  fall  and  tense.  The  arter}'  fills 
and  empties  quickly.  This  is  best  demonstrated  b}'  a 
sphygmographic  tracing  in  which  the  ascending  and  de- 
scending lines  of  the  pulse-wave  form  an  acute  angle. 
The  rapid  emptj'ing  of  the  artery  is  due  to  the  fact  that 
it  both  empties  forward  into  the  cai)illaries  and  back- 
ward into  the  ventricle.  On  the  descending  line  the 
diastolic  notch  is  usually  shallow,  and  approaches  the 
respirator}''  line.  In  the  carotid  s3^stolic  thrills  can 
sometimes  be  felt. 

If  there  is  stenosis  of  the  aortic  orifice  the  blood 
within  the  ventricle  is  under  unusual  pressure.  This 
causes  a  slight  or  moderate  stretching,  or  dilating  of 
the  ventricle.  But  to  force  the  blood  through  the 
narrow  opening  the  heart  must  work  hard,  and  there- 
fore hypertrophies.  The  aorta  fills  slowly.  The  auri- 
cles and  right  ventricle  ma}'  remain  unchanged.  The 
enlaro-ement  of  the  left  never  attains  the  i2*reat  size  that 
it  does  when  there  is  aortic  insufficiency,  as  it  is  not 
dilated  by  an  unusual  quantity  of  blood. 

The  prjiecordia  is  prominent  in  chests  that  are  plastic. 
The  apex-beat  is  usually  visible,  and  is  generally  strong 
and  lifting  when  felt;  but,  in  some  cases,  it  is  unusually 
M'eak,  and  can  scarcely  be  perceived.  This  is,  at  least  in 
part,  due  to  the  absence  of  recoil,  as  the  aorta  is  slowly 


246  Diseases  of  the  Endocardium. 

tilled,  and,  therefore,  straightened  less  than  is  normal. 
The  apex  is  depressed  and  disi)kiced  to  the  left.  Palpa- 
tion often  reveals  a  thrill  in  the  second  intercostal  space 
adjacent  to  the  sternum.  B\'  percussion  the  area  of  car- 
diac dullness  is  found  to  be  moderatelj'  increased  to  the 
left,  and  rarely  to  the  right.  Auscultation  demonstrates 
a  systolic  murmur  which  is  loudest  in  the  second  right 
intercostal  space,  adjacent  to  the  sternum.  Usually,  it 
can  be  heard  elsewhere,  over  the  heart,  and  mn}'  even 
obscure  the  other  heart-sounds.  It  is  occasionally  heard 
extensively  over  the  che.st  and  in  the  back.  It  can  be 
traced  along  the  aorta,  and  heard  almost  always  in  the 
carotids.  Usuallj',  the  second  heart-sound  is  obscured 
over  the  aorta  and  carotids,  and  often  over  the  pul- 
monarv  artery.  Generally,  it  can  be  heard  at  the  apex. 
Except  over  the  aorta  the  normal  cardiac  sounds  ma}^  be 
heard,  but  oftenest  the  murmur  is  transmitted  somewhat 
to  all  parts  of  the  heart. 

The  pulse  is  often  slow  and,  as  compared  with  the 
apex-beat,  is  retarded.  The  pulse  is  characteristically 
liard  and  small.  The  artery  fills  and  empties  slowly. 
This  latter  fact  is  best  demonstrated  b}'  a  sphvgmogram, 
in  which  the  lines  are  seen  to  ascend  and  descend  grad- 
ually and  to  form  a  round-topped  wave. 

When  the  mitral  valves  are  affected,  changes  take 
place  in  the  heart  much  more  extensivel}'  than  when 
the  aortic  valves  are  the  locus  of  disease.  If  the  mitral 
valves  are  insufficient,  blood  will  flow  into  the  left 
auricle,  as  usual,  by  the  pulmonary  veins,  and  in  the 
usual  amount,  but  it  will  also  flow  in  from  the  left  ven- 
tricle. Necessarily  the  auricle  must  dilate,  in  order  to 
hold  this  abnormal  quantity  of  blood.  Moreover,  as 
the  left  auricle  contains  an  unusual  amount  of  blood, 
the  ventricle  also  must  dilate  to  hold  it  when  it  is  expelled 


Chronic  Valvular  Disease.  247 

from  the  auricle.  The  overfilling  and  stretching  of  the 
auricle  increases  the  blood-pi'essure  within  it,  and  also 
in  the  pulmonar^^  veins.  If  the  mitral  leakage  is  con- 
siderable, congestion  of  the  pulmonary  capillaries  results, 
and  increased  blood-pressure  is  transmitted  through 
them  into  the  pulmonarj^  arter}'.  A  heightened  blood- 
pressure  in  the  pulmonary  artery  leads  to  slight  or 
moderate  dilatation  of  the  right  ventricle,  and  often  to 
ver^'  consideral)le  hj^^ertrophy  of  it.  The  leakage  at 
the  mitral  orifice  must  be  compensated  by  right  ven- 
tricular hypertrophy,  for  the  weak  walls  of  the  auricle 
are  capable  of  very  little  hj^pertroph}^,  and  certainly  not 
of  enough  to  compensate  for  the  results  of  the  usual 
mitral  lesions.  Very  moderate  hj-pertrophy  of  the  left 
ventricle  is  produced  by  the  necessity  of  propelling  a 
somewhat  larger  amount  of  blood  than  is  normal. 

From  these  anatomical  changes  one  can  reason  to 
most  of  the  phj^sical  signs  that  are  characteristic  of  the 
lesion.  The  praecordia  is  usually  prominent.  The  apex- 
beat  may  be  normally  located,  but  generally  is  immedi- 
atelj^  beneath  the  left  nipple  or  to  the  left  of  it.  The 
beat  is  diffuse.  The  end  of  the  sternum  is  often  raised 
at  each  systole.  This  is  significant  of  hypertrophy  of 
the  right  ventricle.  In  the  epigastric  region  throbbing 
is  almost  uniformly  visible.  Occasionally,  it  can  be  seen 
to  the  right  of  the  lower  part  of  the  sternum.  This 
generally  happens  when  the  right  ventricle  is  much 
dilated.  Rarely,  a  systolic  impulse  has  been  seen  over 
the  pulmonar}^  arterj^  It  occurs  when  that  vessel  is 
distended  and  lies  against  the  chest-wall.  Over  the 
pulmonary  vessel  a  sharp  impulse  can  sometimes  be  felt, 
which  is  synchronous  with  the  closure  of  the  pulmonary 
semilunars.  At  the  apex  a  S3'stolic  thrill  is  of  frequent 
occurrence.     Occasionall}',  it  can  be  felt  only  when  the 


248  Diseases  of  the  Endocardium. 

patient  leans  forward  or  to  the  left,  or  after  hurried 
movements  have  been  made.  The  area  of  cardiac  dull- 
ness is  broader  than  normal.  It  is  often  extended  to 
the  left,  but  alwa3's  noticeabl}'  and  sometimes  greatlj'  to 
the  right.  It  usually  extends  to  the  right  of  the  right 
sternal  border. 

Auscultation  reveals  a  s3'stolic  murmur  which  is 
loudest  at  the  apex.  It  can  sometimes  be  heard  all  over 
the  heart.  In  the  rare  cases  in  which  the  appendix  of 
the  left  auricle  is  distended  and  wrapped  around  the 
base  of  the  pulmonary  vessel,  it  ma}^  be  heard  loudest 
over  that  vessel ;  that  is,  in  the  second  left  intercostal 
space.  It  can  usually  be  traced  to  the  left  of  the  apex, 
into  the  axillarv  region,  and  sometimes  to  the  back.  It 
is  least  frequentlj-  plainl}^  heard  over  the  aorta ;  that  is, 
in  the  right  second  intercostal  space.  A  S3'stolic  sound 
is  also  often  audible,  and  is  synchronous  with  the 
murmur.  It  m^y  be  transmitted  from  the  tricuspids  or 
produced  by  the  ventricular  contractions.  Over  the 
pulmonary  vessel  an  accentuated  or  sharply  clicking 
sound  is  produced  b3'  increased  pressure  in  the  pulmo- 
nar3^  vessels  and  b3^  hypertroph3'  of  the  right  ventricle. 
The  radial  pulse  is  not  characteristic,  but  is  especiall3' 
apt  to  be  irregular  if  there  is  imperfect  compensation. 
The  sph3'gmogram  is  not  peculiar,  though  it  usually 
demonstrates  a  low  arterial  pressure. 

Mitral  insufRcienc3'  occurs  more  frequentl3'  than  an3' 
other  chronic  valvular  lesion.  It  is  very  often  com- 
bined with  mitral  stenosis,  the  phN'sical  signs  of  which 
are  wanting.  Compensation  may  be  quite  perfect,  but 
^•arel3'  is  as  perfect  as  it  may  be  when  the  aortic  valves 
are  affected.  Recoveries  have  been  reported.  I  have 
m3'self  observed  cases  in  which  mitral  S3^stolic  murmurs 
and  dilatation  of  tlie  right  heart  completel3'  disappeared 


Chronic  Valvular  Disease,  249 

that  bad  originated  in  an  attack  of  acute  articular 
rheumatism.  But  the  patients  had  become  anaemic 
during  their  rheumatic  attack,  and  I  did  not  feel  confi- 
dent that  the  murmur  was  the  result  of  a  valvular 
lesion,  for  in  anaemia  and  fever  dilatation  of  the  right 
ventricle  and  systolic  apical  murmurs  ma}'  exist.  A 
diagnosis  of  a  mitral  lesion  is  sometimes  difficult.  An 
accentuation  of  the  second  pulmonary  sound  is  confirma- 
tor}'  of  a  valvular  lesion,  as  is  also  a  wide  distribution 
of  the  murmur,  especially  to  the  left  of  the  heart. 

If  there  is  uncomplicated  stenosis  of  the  mitral 
valves^  less  extensive  changes  are  usually  wrought  than 
by  insufficienc}'.  Because  of  the  obstruction  to  the 
outflowing  current  from  the  left  auricle,  blood-pressure 
within  it  is  increased.  This  dilates  the  auricle  some- 
what. The  increased  pressure  is,  however,  transmitted 
througli  the  pulmonary  vessels  to  the  right  ventricle, 
which  also  dilates,  and,  in  order  to  compensate  for  the 
mitral  obstruction,  hypertrophies.  Tlie  left  ventricle 
does  not  hypertroph}',  and  may  even  diminish  in  size, 
because  the  blood  within  it  is  under  low  pressure,  and 
may  even  be  diminished  in  amount,  because  of  tlie  mitral 
obstruction. 

The  praecordia  is  usuall}-  prominent  in  those  whose 
ribs  and  cartilages  are  pliable.  Dilatation  and  hyper- 
trophy of  the  right  ventricle,  as  in  mitral  insufl^iciency, 
produce  a  diff'use  cardiac  impulse,  which  is  visible  be- 
neath the  sternum  or  lifting  it,  and  sometimes  in  the 
intercostal  spaces  to  the  right  of  it.  The  apex-beat  is 
seen  to  the  left  of  the  left  nipple  when  the  right  ven- 
tricle is  much  enlarged. 

A  fremitus,  or  thrill,  can  often  be  felt  at  the  apex. 
It  is  presystolic,  or,  rarelj^  diastolic.  It  is  usuall}'  con- 
fined to  the  apex.     Often  it  is  best,  or  only,  felt  with  the 

11* 


250  Diseases  of  the  Endocardium. 

patient  reclining  upon  his  left  side  or  leaning  forward, 
or  when  pli3sical  exertion  or  mental  excitement  quickens 
and  makes  forceful  the  heart's  movements.  A  diastolic 
impulse  may  be  felt  over  the  pulmonary  arterj',  in  the 
second  left  intercostal  space,  as  in  mitral  insufficiencj'. 
Percussion  will  demonstrate  a  right-sided  enlargement 
of  the  heart.  The  shape  of  the  area  of  dullness  is  sim- 
ilar to  that  in  mitral  insufficienc3\  Murmurs  may  be 
wanting,  but  usuallj^  a  pres3^stolic,  or,  rarel}',  a  diastolic, 
one  is  heard  at  the  apex.  The  murmur  is  often  heard 
less  plainlj'  at  the  end  of  the  sternum,  and  is  least  likel}^ 
to  be  heard  over  the  aorta.  The  heart-sounds  over  the 
aorta  are  often  feeble.  The  second  sound  over  the  pul- 
monar}'  is  accentuated.  At  the  apex  the  first  sound  is 
clearlj'  heard,  the  second  is  sometimes  absent.  Earel}', 
a  re-duplicated  diastolic  sound  is  heard  over  the  aorta 
and  pulmonar}^  artery.  This  is  due  to  the  low  blood- 
tension  in  the  former  and  high  tension  in  the  latter, 
which  causes  the  valves  in  the  two  vessels  to  close  at 
different  times.  Systolic  murmurs  raav  be  heard  over 
the  carotids  and  subclavian.  The  pulse  is  usuall}'  small 
and  soft ;  it  may  be  irregular,  and  often  is  fast. 

A  mitral  stenosis  is  rare,  except  as  it  is  combined 
with  insufficienc}'.  It  ma}'  graduall}'  develop  out  of  the 
latter  by  the  growth  of  verrucosities  or  b^^  hardening  of 
the  valves.  The  prognosis  is  less  favorable  than  in 
mitral  insufficiency. 

Pulmonary  insufficiency  and  stenosis  repeat  upon 
the  right  side  of  the  heart  what  aortic  insufficienc}-  and 
stenosis  cause  on  the  left.  As  these  lesions  are  oftenest 
congenital,  prsecordial  prominence  is  usually  produced 
in  the  infant's  pliable  thoracic  wall.  The  impulse  is 
seen  and  felt  to  be  diffuse,  and  especiallj^  is  it  demon- 
strable  at  the  end  of  the  sternum.     Thrills  are  often 


Chronic  Valvnlar  Disease.  251 

felt.  If  there  is  insufficiency,  they  will  be  diastolic,  and 
will  be  felt  best,  or  exclusivel3%  in  the  second  left  inter- 
costal space.  If  there  is  stenosis,  the}'  will  be  systolic, 
and  felt  best  in  the  same  place,  but  nia}^  be  diffused  over 
the  entire  henrt.  Percussion  demonstrates  a  right-sided 
enlargement  of  the  heart.  Auscultation  reveals  mur- 
murs, which  are  best  heard  over  the  pulmonary  artery-, 
but  may  be  transmitted  toward  the  end  of  the  sternum. 
If  there  is  insufficiency,  the  murmur  is  rarel}^  heard  at 
the  apex,  but  maj-  be  if  there  is  stenosis.  Tiie  diastolic 
sound  ma}'  be  absent  over  the  pulmonary  artery  or 
feeble ;  at  the  other  valvular  orifices  the  sounds  may  be 
normal.  If  there  is  insufficiency,  a  S3'stolic,  as  well  as 
diastolic,  murmur  is  sometimes  heard  in  the  second  left 
intercostal  space,  which  is  due  to  irregular  vascular 
vibrations,  because  of  excessive  tension,  not  necessarily 
to  a  complicating  stenosis.  Unfortunatel}^,  accidental 
murmurs  often  simulate  pulmonar}'  stenosis.  They  do 
not  generally  produce  a  fremitus,  and  are  less  likel}'  to 
be  accompanied  by  an}'  considerable  change  in  the  right 
ventricle.     Steiiosis  usually  causes  cyanosis. 

Lesions  of  the  tricuspid  valves  are  rare,  and  when 
they  occur  are  usually  congenital,  though  they  may  be 
secondary  to  mitral  lesions.  Stenosis  is  so  rare  that  it 
is  of  no  clinical  importance.  Its  symptoms  can  be 
theoretically  constructed  with  ease.  Tricuspid  insuffi- 
ciency is  not  uncommonly  due  to  dilatation*  of  the  right 
auriculo-ventricular  orifice,  though  the  valves  remain 
normal.  This  is  likely  to  occur  when  the  right  ventricle 
dilates  greatly.  Cardiac  dullness  is  increased  to  the 
right  in  this  case.  A  systolic  murmur  is  heard  over  tlie 
tricuspids.  I  have  observed  a  case  in  which  this  mur- 
mur was  so  loud  that  it  obscured  all  other  cardi:>c 
sounds,  although   it  was  produced   by   relative   insuffi- 


252  Diseases  of  the  Endocardium. 

cienc}'.  It  disappeared  under  treatment,  and  the  primary' 
mitral  lesion  was  revealed.  Systolic  sounds  may  be 
heard  over  the  jugular  and  cervical  veins,  and,  if  the 
venous  valves  afe  insufficient,  murmurs  may  be  heard. 
A  venous  pulse  is  especially  characteristic  of  tricuspid 
insufficienc3\  It  ma}'  be  seen  and  felt.  It  is  oftenest 
detected  in  the  jugular  veins  and  liver;  less  frequently, 
in  the  legs  and  other  distant  vessels.  The  pulsations 
are  not  evident,  even  though  there  is  tricuspid  insuffi- 
cienc}-,  unless  the  venous  valves  are  incompetent  from 
dilatation  of  the  vessels.  The  venous  pulse  is  due  to 
stasis  in  the  vessels  and  the  transmission  of  the  pulse 
from  the  heart.  Rarel}',  both  the  auricular  and  ventric- 
ular contractions  produce  a  pulse,  but  usually  it  is  the 
latter  onlv  that  does.  When  the  tricuspids  are  insuffi- 
cient the  right  auricle  is  distended  with  blood,  dilates, 
and  li3^pertrophies  ;  the  right  ventricle  dilates  a  little. 
The  increased  tension  in  the  auricle  is  transmitted  to 
the  venae  cavse  and  veins.  The  jugular  pulse  can  often 
be  felt,  as  well  as  seen.  It  can  be  best  distinguished 
from  a  pulsation  of  the  underlying  arterj'  by  compress- 
ing the  vein  in  the  middle,  when  it  will  collapse  below 
the  point  of  compression  if  there  is  not  a  true  venous 
pulse;  if  there  is,  it  will  continue  to  be  seen  and  felt. 
A  venous  pulse  is  ver}-  rarel}''  produced  when  there  is 
hypertroph}^  of  the  right  ventricle  and  no  tricuspid 
insufficienG3^  Hepatic  pulsation  is  best  demonstrated 
by  placing  the  hands  over  the  liver,  in  front  and  behind, 
when  the}'  can  be  felt  to  separate  with  each  impulse  of 
the  heart.  The  liver  often  becomes  enormously  dis- 
tended by  this  passive  congestion.  There  is  low  press- 
ure in  the  pulmonary  arter\-.  'IMiis  tends  to  diminish  or 
prevent  pulmonary  congestion  and  consequent  dyspncea; 
therefore,  the  liver  may  be  enormously  enlarged   when 


Chronic  Valvular  Disease.  253 

there  is  relative  tricuspid   insufficienc)^  and  a  primary 
mitral  lesion,  though  there  is  very  little  dyspnoea. 

A  combination  of  valvular  lesions  occurs  very  often. 
They  frequentl}'  hasten  cardiac  failure  and  rarely  so 
counteract  one  another  as  to  retard  it.  Stenosis  and  in- 
sufficiency may  co-exist  at  the  same  valve,  or  two  valves 
ma}^  be  simultaneously  involved.  Combined  lesions 
may  be  said  to  be  the  rule,  but  are  least  likely  to 
occur  when  the  arterial  orifices  are  involved.  Thouoh 
combined  lesions  are  so  common,  they  usually  cannot  be 
diagnosed  during  life,  for  one  or  the  other  will  so  f;ir 
predominate  that  the  clinical  picture  will  be  of  a  simple 
lesion.  Sometimes  the  symptoms  of  a  secondary  lesion 
in  a  combination  will  supplant  the  primar3\  As,  for 
instance,  in  the  following  cases  :  In  the  first  the  heart 
beat  tumultuously.  There  was  a  loud  s^^stolic  murmur 
plain-ly  audible  at  the  end  of  the  sternum  and  along  its 
right  border.  It  could  be  heard  feebl}'  elsew^here.  No 
other  murmur  was  audible.  The  heart  w^as  considerably 
enlarged  to  the  right,  but  not  to  the  left.  A  diagnosis 
was  made  of  tricuspid  insufficiency^  probably  due  to 
dilatation  of  the  right  ventricle,  which,  in  turn,  was 
caused  b}^  t\  mitral  lesion  and  probably  by  stenosis.  Two 
days  later,  when  the  heart  had  been  slowed  and  some- 
w^hat  contracted  by  digitalis,  the  murmur  fust  heard  was 
gone,  but  at  the  apex  a  low  presystolic  murmur  was  au- 
dible. In  another  case,  when  the  first  examination  was 
made,  tlie  heart  was  beating  reguhirly,  but  rapidly.  A 
loud  diastolic  aortic  murmur  was  heard,  and  a  low  sys- 
tolic one  was  suspected,  but  not  plainl3'  audible.  Some 
days  later,  when  the  heart  was  benting  slowl}-,  the  dias- 
tolic murmur  was  almost  gone,  but  the  systolic  one  was 
plain.  In  this  case  there  was  evidently  a  combined  in- 
sufficiency  and    stenosis  at  the   aortic  orifice,  and  the 


254  Diaeaaes  of  the  Endocardium. 

murmurs  were  chiinged  in  character  by  the  rapidity  of 
the  blood-stream.  Such  a  combination  as  this  last  may 
retard  tlie  heart's  dilatation  and  muscular  weakness  ;  for 
the  stenosis  will  prevent  a  reflux  of  so  large  a  quantity 
of  blood  into  the  ventricle  during  diastole  as  might 
otherwise  take  place,  and  so  retards  or  prevents  great 
ventricular  dilatation.  During  systole  the  effect  of  the 
insufficiency  is  lessened  b}'  the  stenosis.  Occasionally, 
the  character  of  the  murmurs  at  different  orifices  ma}' 
enal)le  one  to  diagnose  combined  lesions,  or  if  both  a 
S3'stolic  and  diastolic  murmur  exist  we  can  generall}' 
conclude  that  there  is  a  combination  of  lesions.  An  ex- 
ception to  this  general  statement  must  be  made,  since 
systolic  murmurs  may  be  produced  b}-  irregular  vascular 
vibrations  and  ma}'  be  accidental. 

Prognosis. — In  general,  it  ma}-  be  said  that  chronic 
valve-lesions  are  unlavorable  to  long  life.  If  compensa- 
tion is  good,  life  will  not  be  shortened.  Sudden  death 
does  not  often  result  from  them.  Simple  aortic  lesions 
are  least  likely  to  precipitate  the  symptoms  of  heart 
fatigue  or  exhaustion.  If,  because  of  one's  social  po- 
sition or  occupation,  it  is  possible  to  avoid  all  exhaust- 
ing exertion  and  still  to  so  live  as  to  preserve  generai 
health  and  vigor,  the  chances  of  a  long  life  are  good. 
Unfavorable  symptoms  are:  dyspnoea,  i)alpitati()n,  in- 
creasing dilatation  of  the  heart,  weakness  of  the  apex- 
beat,  oedema,  bronchitis,  or  other  intercurrent  disease. 
Even  when  oedema  is  considerable,  and  arythmia  and 
feeble  pulsation  characterize  the  heart's  action,  it  is 
often  possil)le,by  persevering  treatment,  to  remove  these 
symptoms,  and  by  a  careful  regulation  of  habits  of  life 
to  maintain  for  years  sufficient  cardiac  strength. 

Treatment. — We  cannot  modify  the  valvidar  lesion 
by  medicinal  treatment,  but,  l)y  strengthening  the  heart 


Chronic  Valvular  Disease.  255 

and  b}'  removing  nil  impediments  to  the  circulation,  com- 
pensation wvAy  be  established.  Ph3'sical  fatigue  must 
be  avoided,  and  in  cases  in  which  compensation  is  lack- 
ing any  exertion  must  be  avoided.  There  are  many  pa- 
tients who  do  not  exhibit  signs  of  weak  heart  except 
after  sudden  or  violent  exertion.  Such  individuals 
must  be  especially  careful  not  to  overdo.  Indigestion 
and  constipation  impede  the  circulation  and  help  to 
fatigue  the  heart.  The}'  must  be  corrected  or  prevented. 
Changes  of  climate  and  habits  of  life,  which  will  con- 
tribute to  one's  general  vigor,  must  be  encouraged.  So 
much  exercise  as  can  be  taken  without  exciting  the 
heart  is  useful,  but  in  many  cases  all  active  exertion  is 
contra-indicated.  Under  such  circumstances,  gentle, 
passive  exercise — massage — may  be  resorted  to  with 
good  results,  as  it  helps  to  maintain  a  better  peripheral 
circulation.  When  flagging  of  the  heart  is  evidenced 
by  persisting  rapidity  of  the  pulse,  and,  perhaps,  aryth- 
mia,  digitalis,  strophanthus,  and  their  congeners,  must 
be  used  to  strengthen  and  slow  it.  They  need  not  ])e 
given  so  often,  or  in  their  stead  caffeine,  strj^chnia,  and 
other  bitters  may  be  used,  if  the  heart  is  onh'  accel- 
erated by  exercise  or  general  movements.  Iron  is 
usually  indicated,  as  in  other  cases  of  heart-fatigue  and 
weakness.  The  treatment,  in  a  word,  must  be  the  same 
as  has  been  described  for  these  conditions  (page  222). 

Complications  such  as  oedema  and  bronchitis  must 
be  met  as  in  other  cases  of  weak  heart.  When  passive 
congestion  causes  them,  heart  tonics  like  digitalis  will 
often  relieve  them  perfectly.  At  other  times  the  usual 
treatment  for  such  complications  (see  page  225)  is  also 
needed, 


DISEASES  OF  CARDIAC  INNERVATION. 


CHAPTER   XXVIII. 
Tachycardia,  or  Nervous  Palpitation. 

Symptoms. — By  tachj^carcUa  is  meant  a  rapid  or 
forceful  beating  of  the  heart,  wh'ch  is  subjectively 
recognizable,  and  is  not  due  to  organic  heart  disease. 
The  heart  may  beat  rapidly  and  forcefull}'  \Yithout  being 
subjectively  recognizable,  but  does  not  then  constitute 
tachycardia.  This  often  occurs  in  cases  of  chronic 
valvular  disease.  Tachycardia,  when  violent,  is  accom- 
panied b}^  other  varying  symptoms.  Attacks  of  nervous 
palpitation  ma}^  last  onl}"  a  few  minutes,  a  few  hours,  or 
even  for  several  days.  Between  the  attacks  are  inter- 
vals of  varying  length  of  normal  cardiac  action. 

Sometimes  premonitoiy  S3^mptoms  give  warning  of 
an  attack.  These  vary  greatly  in  character  in  in- 
dividual cases.  The^'  ma}^  consist  in  a  feeling  of  terror 
or  apprehensiveness,  or  the  heart  will  apparently  stop. 
Dyspnoea,  slight  syncope,  vertigo,  cold  sweat,  or  head- 
ache foretell  an  attack  in  others.  Often  the  paroxysms 
occur  without  premonition. 

The  attack  is  characterized  by  rapid  throbbing  of 
the  heart  and  a  diffuse  and  lifting  apex-beat.  The 
pulsations  are  felt  b}^  the  sufferer  and  ma3'  increase  the 
anxiety,  fear,  vertigo,  or  deepen  the  syncope.  In  many 
cases  the  heart  is  also  irregular.  The  first  sound  of  the 
heart,  especially  at  the  apex,  may  be  metallic  in  quality 
or  murmur-like.  The  changed  rapidity  of  the  blood's 
tlow  or  the  abnormal  muscular  contractions  are  ac- 
(256) 


Tachijcardia^  or  Nervous  Palpitation.  257 

countable  tor  these  peculiarities.  At  the  apex  the 
diastolic  sound  is  often  feeble  or  almost  inaudible. 
This  is  probably  due  to  the  imperfect  filling  of  the  aorta 
and  pulmonar}'  artery  by  each  of  the  quickly-repeated 
cardiac  contractions.  Very  i-arely,  tlie  heart-beats  are 
audible  at  a  little  distance  from  the  patient.  Usuall}', 
the  carotids  throb  Yiolentl3',  and  in  them  a  systolic 
murmur  aud  thrill  can  frequently  be  heard  and  felt. 
'V\\Q  radial  artery  is  generallj'  full, hard, and  quick;  rarely, 
it  is  small  and  soft.  Two  hundred  or  more  beats  per 
minute  may  be  made.  D\'spnoea  on  exertion  generally 
exists  while  there  is  i)alpitation,  and  sometimes  it  is 
experienced  even  when  the  sufferer  is  quiet.  It  leads 
him  often  to  seek  an  upright  position,  for  it  is  increased 
b}'  recumbence.  Speech  may  become  jerky  because  of 
the  throbbing  against  the  lungs.  Epigastric  pain  is 
sometimes  complained  of.  The  face  often  becomes 
flushed  and  moist,  and  rarely  is  pale  or  cold.  Tempo- 
rarih',  there  may  be  a  slight  rise  of  temperature. 
Frequenth',  dizziness  and  faintness  are  felt. 

Attacks  commonly  terminate  suddenl}^,  but  palpita- 
tion ma}'  lessen  slowly  In  many  of  the  cases  in  which 
tach3'cardia  frequently  recurs  there  is  constantly  a 
quicker  beating  than  is  natural,  which  occasional!}'  in- 
creases and  produces  tlie  subjective  symptoms  that  have 
been  described.  Attacks  often  subside  with  eructation  of 
gases  from  the  stomach  or  with  vomiting  or  defecation. 

Tachycardia  can  be  readily  distinguished  from  endo- 
cardial disease  by  the  absence  of  a  persistent  murmur 
and  evidence  of  changes  in  the  size  of  the  heart's  cavi- 
ties. It  is  more  difilcult  to  distinguish  between  it  and 
affections  of  the  heart-muscle.  It  can  only  be  done  by 
carefully  studying  the  history  of  tlie  case  and  the  excit- 
ing causes  of  the  palpitation. 


258  Diseases  of  Cardiac  Innervation. 

It  is  impossible  to  designate  tlie  part  of  the  nervous 
system  that  is  chiefly  involved  in  each  case.  The  ner- 
vous disturbance  may  originate  in  the  brain  from  hfiem- 
orrhage,  tumor,  softening,  etc.,  or  much  oftener  from  jo}^ 
fright,  or  violent  mental  emotions.  I  have  frequently 
seen  quite  persistent  attacks  excited  by  fright.  In  one 
woman  severe  attacks  re^curred  almost  dailj'  for  two 
years,  which  originated  from  excitement  produced  by 
lightning  that  struck  near  her.  Another  similar  case 
was  excited  by  witnessing  a  distressing  and  fatal  railway 
accident. 

Causes. — It  may  be  caused  by  compression  of  the 
pneumogastric  or  sympathetic  nerves,  by  tumors,  or  by 
other  lesions.  Futile  attempts  have  been  made  to  clin- 
ically recognize  cases  due  to  paralj'sis  of  the  heart's 
inhibiting  nerves  and  those  due  to  irritation  of  the 
excito-motors. 

Exhaustion  of  the  nervous  system,  as  b}^  mental 
overwork,  excessive  vener}',  loss  of  blood,  excessive 
lactation,  will  produce  tach3'cardia.  These  same  condi- 
tions predispose  to  it,  as  do  also  anaemia,  convalescence 
from  severe  disease,  or  other  conditions  of  general  en- 
feeblement.  It  is  especiall3'  apt  to  occur  in  those  who 
are  hysterical  and  those  with  a  gout}'  diathesis. 

Reflex  attacks  are  common ;  indigestion,  constipa- 
tion, uterine,  renal,  and  hepatic  colic  nre  frequent 
excitors  of  them.  The  excessive  use  of  tea,  coffee,  and 
tobacco  is  one  of  the  commonest  causes.  Attacks  mtiy 
occur  in  childhood,  as  well  as  in  adult  life,  and  may 
occur  in  either  sex. 

Treatment. — Treatment  mnst  var}-  with  the  cause  of 
tach3'cardia  in  individual  cases.  If  predisposing  condi- 
tions or  causes  exist,  they  must  be  corrected  or  removed. 
Anaemia  may  have  to  be  treated,  or  the  nervous  system 


Tachycardia^  or  Nervous  Palpitation.  259 

rested,  £ind  the  whole  body  nourished  in  order  to  remove 
tlie  nervous  excitability,  which  provokes  palpitation. 

Hysterical  palpitation  is  often  difficult  to  prevent. 
If  fright  or  some  other  emotion  excited  it  the  avoidance 
of  a  repetition  of  the  emotion  and  mental  diversion 
(such  as  may  be  effected  by  change  of  scene  and  sur- 
roundings, or  of  work, or  mode  of  life)  will  often  produce 
the  best  results.  A  class  of  cases  which  closely  resemble 
hysteria,  though  there  may  be  in  them  no  other  hys- 
terical manifestations,  are  those  in  which  tachycardia 
recurs  often,  and  at  times  is  quite  persistent,  without 
discoverable  exciting  or  predisposing  cause.  They  are 
often  helped  by  the  same  changes  that  aid  the  hystericnl. 
In  both  relief  can  sometimes  be  promptly  obtained  by 
means  peculiar  to  each  individual.  For  instance,  one 
person  may  be  able  to  stop  the- parox3'sms  by  swallow- 
ing bits  of  ice;  another  by  hot  drinks,  another  by  strong- 
coffee,  another  by  drawing  a  long  breath  and  holding  it, 
another  b}' reclining  upon  the  back,  another  by  pressure 
upon  the  abdomen.  These  various  and  idiosyncratic 
modes  of  relief  maj-  change  from  time  to  time  in  the 
same  case. 

The  use  of  large  amounts  of  strong  tea  and  tobncco 
should  be  forbidden  in  all  cases  of  palpitation,  for  the}^ 
may  increase  the  disposition  to  the  affection,  and  often 
are  exciting  causes  of  it. 

It  may  be  necessary  to  empty  the  stomach  by  emet- 
ics when  gastric  fermentation  reflexly  excites  palpitation. 
Persistent  treatment  of  the  gastric  disease  will  remove 
the  cardiac  affection  in  such  cases.  If  the  origin  of  the 
reflex  irritation  is  in  the  uterus  or  other  organ  it  will 
require  especial  treatment. 

When  tachycardia  arises  from  destruction  of  nerve- 
tissue  by  a  structural  disease  of  the  central  or  peripheral 


260  Diseases  of  Cardiac  Innervation. 

cardiac  nervous  meclianism,  no  hope  of  permanent  relief 
can  be  expected. 

Frequently,  an  ice-bag  placed  over  the  heart  will 
check  palpitation.  A  sinapism,  similarl}'  placed,  often 
acts  with  equal  efflcac}'.  Of  drugs,  morphine  oftenest 
gives  relief.  It  must  be  given  in  moderate,  but  not 
somniferous,  doses  :  a  sixteenth,  an  eighth,  or  a  sixth 
of  a  grain  is  usualh'  efficient.  Chloral,  bromides,  ether, 
chloroform,  lu'oscyamns,  and  belladonna  are  also  used 
with  good  results.  In  the  hysterical  cases  bromides  and 
valerian  are  verj^  useful. 

In  anaemic  and  weak  persons  strjxhnia,  ergot,  and 
iron  are  oftenest  beneficial.  Digitalis  ma}'  be  tried,  but 
frequently  proves  inefficient.  It  is  most  useful  in  the 
cases  for  which  str3'chnia  and  iron  are  indicated,  and 
with  them  should  be  used  persistently  for  a  long  time. 

The  constant  electric  current  has  been  applied  to  the 
neck  over  the  pneumogastric  and  to  the  S3'mpathetic 
with  varying  results,  which  have  notj'et  been  so  analyzed 
that  we  can  deduce  indications  for  it. 


SECTION  111, 


Diseases  of  the  Kidneys. 


(261) 


FUNCTIONAL  IN  A  CTIVITY  OF  THE 
KIDNEYS. 


CHAPTER  XXIX. 

IJRiEMIA. 

Natni^e. — Uraemia  is  secondniy  to  various  diseases, 
but  cliiefl}'  to  renal  disorders  which  diminish  the  ex- 
cretion of  nitrogenous  waste.  In  its  most  character- 
istic form,  the  onset  and  course  of  uraemia  is  acute, 
but  obscure  and  variable  symptoms  may  precede  or 
presage  an  acute  attack  and  characterize  its  chronic 
form.  The  symptoms  are  of  nervous  origin.  Then- 
precise  cause  is  unknown.  It  was  early  su})posed  that 
the  retention  of  urea  provoked  them  ;  but  both  experi- 
ment and  clinical  observations  demonstrated  that  the 
quantity  of  retained  urea  was  not  proportioned  to  the 
severity  of  attacks  of  uraemia,  and  that  even  when  con- 
siderable quantities  of  it  were  introduced  into  the  blood 
the  S3anptoms  were  not  always  produced.  An  excess  of 
carbonate  of  ammonia  in  the  blood,  cerebral  anaemia, 
and  oedema  are  other  explanations  that  are  equallj^  un- 
tenable. More  recentl}'  kreatinin  and  kreatin  have  been 
thought  to  be  the  poisons  which  produce  uraemia.  There 
is  little  doubt  but  that  some  product_ot*  tissue-metamor- 
phosis is  the  cause.  It  is  not  known  whether  the  sub- 
stance is  produced  b}^  normal  tissue-changes  and  accu- 
mulates in  the  blood  when  the  kidneys  cease  to  perform 
their  function  properly,  or  whether  it  results  only  from 
pathological  tissue-changes.  Cholemia  and  diabetic 
coma  resemble  uraemia,  and  may  have  a  similar  origin. 

(263) 


264  Functional  Inactivity  of  the  Kidneys. 

Cannes. — Untmia  occurs  when  urea-produciDg  sub- 
stances are  retained  in  the  blood,  or  when  the}'  are 
tbrraed  in  excess.  It  usuall\'  occurs  when  the  urine  is 
much  diminished  in  amount,  or,  at  least,  when  the  nitrog- 
enous elements  of  the  urine  are  diminished.  Mechani- 
cal suppression  of  the  urine  maj'  cause  it.  Uraemia 
rarely  occurs  when  diuresis  is  profuse.  Ammoniacal 
decomposition  of  the  urine  in  the  bladder  or  pelvis  of 
the  kidney,  especiall}'  if  it  is  not  freely  voided,  and  is, 
therefore,  absorbed,  will  cause  uraemia  or  symptoms 
resembling  it,  that  are  sometimes  called  ammonsemia. 
Of  kidne}'  diseases,  chronic  interstitial  nephritis  is 
oftenest  productive  of  uraemia.  Acute  nephritis  is  next 
most  likelj'  to  cause  it,  and  chronic  parenchymatous 
nephritis  is  least  likely  to.  It  oftener  complicates  scar- 
latinal than  diphtheritic  nephritis.  It  is  rarely  asso- 
ciated with  waxy  kidne}'  or  passive  congestion,  but 
often  with  the  renal  disorders  that  accompan}'  preg- 
nanc3% 

Symptoms. — The  variable  and  numerous  sj-mptoms 
which  often  precede  acute  uraemia  are  called  prodromata, 
or  are  coUectivel}'  named  chronic  uraemia.  Headache  is 
one  of  the  commonest  of  these.  It  is  usually  most 
severe  in  the  morning,  and  is  often  occipital.  It  ma}', 
however,  occur  at  other  times,  and  may  be  variously 
located.  Gastric  disturbances  are  also  common,  but  are 
not  peculiar.  Anorexia  onl}^  ma}'  occur  in  one  case, 
nausea  and  vomiting  in  another,  flatulent  indigestion  in 
a  third,  or  all  these  symptoms  successively  in  others. 
These  symptoms  must  be  looked  upo.n  with  suspicion 
when  they  occur  in  the  course  of  a  nephritis.  A  case 
under  my  own  observation  during  this  winter  illustrated 
their  importance.  A  young  man  suffered  from  chronic 
parenchymatous  nephritis,  and  had  repeated  attacks  of 


Uraemia,  265 

anorexia  and  vomiting,  which  lasted  for  days.  There 
was  no  apparent  cause  for  them.  They  were  regarded 
uraemic  symptoms,  and  were  promptly  relieved  by  dia- 
phoretics and  diuretics.  Unfortunately,  he  at  last 
refused  to  submit  to  sweating,  and  the  gastric  symptoms 
culminated  in  acute  uraemia.  Diarrhoea  is  also  a  fre- 
quent prodromal  symptom.  Occasionally,  intense  pru- 
ritus suggests  a  uraemic  state.  In  other  cases,  or  alter- 
nating with  these  symptoms,  asthma  may  occur.  The 
d3'spnoeic  paroxysms  resemble  perfectly  those  of  asthma 
of  a  different  origin.  (See  page  3.)  As  in  a  case  now 
under  my  observation,  asthma  often  alternates  with 
gastric  symptoms.  Occasionally,  insomnia  is  a  promi- 
nent and  distressing  symptom  of  uraemia.  Blindness 
may  develop  suddenly,  last  for  a  few  days,  and  as  sud- 
denly disappear.  Its  cause  is  unknown.  Deafness  or 
buzzing  or  ringing  in  the  ears  may  occur,  either  coinci- 
dently  or  independently^  Numbness  of  the  skin  and 
formication  are  other  variable  premonitor}'  S3'mptoms. 
Delirium  or  an  apmirent  intoxication  may  also  occur  in 
chronic  nraemia./Several  times  I  have  observed,  during 
the  few  hours  just  preceding  an  acute  attack,  hyperses- 
thesia  and  pain  in  the  skin  resembling  a  cutaneous 
rheumatism.  In  one  case  there-JYas,  for  moi-e  than  two 
weeks  prior  to  the  acute  and  fatal  attack,  persistent, 
and  at  times  almost  unbearable,  shifting  pain  in  the 
extremities. 

The  symptoms  of  acute  uraemia  are  definite  in  char- 
acter and  easily  recognizable.  The^^  consist  in  convul- 
sions and  coma.  Coma  occurs  almost  invariably,  and  is 
usually  accompanied  b}-  convulsions,  but  it  ma}'  occur 
without  them.  It  generally  begins  as  apathy,  which 
deepens  into  somnolence,  and  finally  into  complete 
unconsciousness.     These  attacks  may  graduall}^,  within 

12    M 


266  Functional  Inactivity  of  the  Kidneys. 

a  few  hours,  pass  off,  or  may  last  for  days.  The  patient 
generall^^  breathes  loucll}^,  at  times,  if  not  continuously. 
Respiration,  also,  is  often  irregular,  or  it  may  be  of  the 
type  known  as  Cheyne-Stokes.  Death  may  occur  b}^  a 
gradual  deepening  of  the  coma,  but  usually  results  from 
convulsions,  in  the  course  of  which  respiration  ceases. 

In  other  cases  convulsions  occur  suddenly,  and 
unconsciousness  only  lasts  during  them.  The}-  then 
resemble  epileptic  seizures.  Sometimes  twitchings  of 
the  muscles  are  limited  to  a  small  group  oi*  to  one*  side 
of  the  body.  The  attacks  may  occur  at  intervals  of 
days  or  weeks,  but  usually  recur  frequentlj'.  When 
severe,  they  may  repeat  themselves  every  ten  or  twenty 
minutes,  or  even  oftener.     Usuall}',  coma  exists  between 

^the  paroxysms.  If  the  disease  take  a  favorable  course, 
convulsions  will  occur  at  longer  intervals,  or  will  finally' 
cease  ;  or,  if  a  fatal  course,  they  increase  in  frequency, 
severity,  and  duration.  When  chronic  nephritis  dis- 
poses a  patient  to  uraemia,  he  will  usuall}^  suffer  from 
the  chronic  form  of  the  maladj^  even  if  he  recoveiC^rom 

,  the  acut^,-WDuring  convulsions  the  bodily  temperature 
is  oftenelevated,  but  ma}-  be  even  subnormal.  The 
pulse  is  usually  quick,  soft,  and  small.  It  often  becomes 
irregular.  Just  before  an  acute  attack  it  is  sometimes 
abnormally  slow.  During  ursemic  attacks  the  pupils  are 
usuall3'  normal  or  large.  The  sweat  and  sputa  of  uriemic 
patients   often  exhale  a   urinous  odor.     Urea  has  been 

■found  in  them,  and  sometimes  crj^stallizes  on  tlie  skin 
or  in  the  hair  of  the  head  or  face.  The  urine  is  usually 
diminished  just  prior  to  and  during  an  attacli,  and  in- 
creases when  it  subsides.     In  these  rarer  cases  in  which 

^    it  increases  before  the   attacks,  its    solid    constituents 

\  diminish  greatly.  During  prolonged  coma  there  is 
"^nerally  incontinence  of  urine  and  faeces. 


Uraemia.  267 

Diagnosis. — A  diagnosis  of  acute  uraemia  is  usually 
easily  made  directly  from  the  assemblage  of  character- 
istic  symptoms.     It   must   sometimes   be  differentiated 
from  other  diseases,  and   especially  from  epilepsj',  apo- 
plexy, and  alcoholism.     The  convulsive  attacks  are  ver}' 
like  those  of  epilepsy.     The  convulsive  movements  are 
seldom  unilateral,  as  the}^  usually  are  in  epilepsy.     In 
the    latter    disease    the    historj'  of   prior    attacks,   the 
""occurrence  of  an  initial  cry,  and  the  absence  of  albumen 
""are   distinctive   symptoms.     Epileptics  become  deeplj^ 
"Somnolent  after  their  attacks,  but  not  truly  comatose. 
— H3"sterical   convulsions    will    seldom   be    mistaken    for 
^^urpemic,  because  the  sufferer  rarely-  becomes   trul}^  un- 
— conscious  ;  the  convulsive  movements  are  oftener  irregu- 
lar, affect  a  single  extremity  at  a  time,  or,  when  general, 
usually  cause  opisthotonos.     Commonly  after  an  attack 
a   large    amount    of   non-albuminous,   limpid    urine    is 
-Voided.     Cerebral  apoplexy  is  sometimes  accompanied 
"  by  convulsions.     They  are   associated   with    paralysis. 
In  epileptic  and  h3'sterical  convulsions  there  is  rarel3'  a 
rise  in  temperature,  which  often  occurs  in  uraemia. 

The  coma  of  uraemia  is  differentiated  from  apoplex}' 
by  coincident  parah'sis  in  the  latter ;  from  opium 
poisoning,  by  its  normal  temperature  and  the  contracted 
pupil.  It  is  distinguished  with  more  difficulty  from 
alcoholism,  as  the  two  conditions  are  occasionally  asso- 
ciated. A  history  of  alcoholism,  the  odor  of  liquor  in 
the  breath,  and  no  rise  of  temperature,  are  indicative  of 
alcoholic  coma. 

Treatment. — The  symptoms  of  chronic  uraemia  always 
indicate  that  the  elimination  of  nitrogenous  matter  b}^ 
the  normal  channels  must  be  stimulated.  In  all  cases 
in  which  uraemia  threatens,  or  ma\'  possibly  occur,  a 
diminution  in  the  quantity-  of  urine,  and  especiall}-  if 


268  Functional  Inactivity  of  the  Kidneys. 

its  specific  gravit}'  is  low,  must  be  regarded  witli  appre- 
liension.  Tlie  kidne3S  must  at  once  be  stimulated  to 
greater  activity. 

Rest  is  essential,  in  order  that  the  amount  of  mus- 
cular waste  may  be  lessened.  An  abundance  of  fresh 
air  is  also  needful,  for  it  insures  as  good  an  oxidation  of 
the  blood  as  is  possible,  and  therefore  as  perfect  meta- 
bolism of  the  tissues  as  is  possible.  A  prescribed  diet  is 
also  of  great  importance.  Albuminous  or  richly  nitrog- 
enous foods  are  contra-indicated,  for  they  will  increase 
the  danoer  of  surchargino-  the  blood  with  the  class  of 
ingredients  which  produce  uraemia.  When  it  is  neces- 
sar^'  to  exercise  the  utmost  caution  to  avoid  uriemia,  a 
patient  maj",  for  a  few  days,  be  fed  onl}'  water-gruels 
made  of  barle^'-meal  or  arrowroot.  Such  a  diet  is  not 
sufficiently  nutritious  to  be  maintained  long.  In  three 
or  four  days  other  forinaceous  articles  must  be  emploj'ed, 
such  as  rice,  potatoes,  and  turnips.  When  the  uraemic 
symptoms  disappear,  milk  and  milk-gruels  may  be  ad- 
ministered. A  complete  mixed  diet  should  be  resumed 
very  gradually,  and  with  much  caution. 

No  specific  remedy  is  known  by  which  the  ursemic 
poison  can  be  counteracted.  Purdy  ("  Bright's  Disease 
and  Kidne}''  Affections ")  recommends,  as  almost  a 
specific  in  chronic  cases,  the  subcnrbonate  of  iron.  It 
should  be  given  in  doses  of  1  to  2  grammes  (20  to  30 
grains)  every  two  to  four  hours.  It  is  said  to  rapidly 
relieve  headache,  nausea,  and  other  s^^mptoms.  My  own 
experiments  with  the  drug  have  afforded  conflicting 
results.  The  mode  of  action  of  this  remed3'  cannot  be 
explained. 

Copious  draughts  of  pure  water  are  also  helpful,  as 
they  will  dilute  the  blood,  thus  making  it  somewhat  less 
toxic,  and  the}'  will  joromote  more  copious  excretions 


Urcemia.  269 

from  the  various  organs  of  elimination.  The  water 
should  be  as  free  from  mineral  products  in  solution  as 
possible,  that  its  dissolving  powers  mny  be  as  great  as 
possible. 

The  salicylates  and  benzoates  have  also  been  fre- 
quently used.  They  unite  with  uric  acid,  and  make  it 
more  soluble  and,  therefore,  more  easily  eliminated.  It 
has  not  been  proven,  however,  tliat  the}'  make  other  im- 
perfectly oxidized  products  of  tissue-change  more  sol- 
uble. Their  utility  in  uraemia  is,  therefore,  a  2^f"io?'i, 
doubtful,  and  it  has  not  been  established  by  their  trial. 
They  are  mildly  diaphoretic,  and  in  this  way  will  do 
good.  In  my  hands  the  salic^date  of  ammonium  is  most 
certain  to  produce  diaphoresis,  and  will  produce  it  more 
copiously  than  any  other  of  this  class  of  remedies.  It 
is,  therefore,  to  be  preferred  in  uraemia.  In  chronic 
cases  it  can  be  best  administered  in  a  hot  drink,  such  as 
hot  lemonade.  The  patient  should  at  the  same  time 
be  well  covered  with  clothing,  that  sweating  may  be 
encouraged. 

In  both  acute  and  chronic  cases  reliance  must  chiefly 
be  placed  upon  drugs  that  promote  elimination  from  the 
skin,  the  intestines,  and  the  kidneys.  Jaborandi,  or, 
better,  its  active  principle,  pilocarpine,  may  be  admin- 
istered to  produce  sweating.  Pilocarpine  will  provoke 
copious  diaphoresis  ver}'  quickh'  if  it  is  administered 
subcutaneousl}'  in  doses  of  6  to  8  milligrammes  (|  to  yV 
grain).  These  drugs,  although  so  efticacious  as  dia- 
phoretics, are  contra-indicated  in  individual  cases  in 
which  the  heart's  action  is  feeble,  for  they  enfeeble  it 
still  more.  Occasionally,  their  administration  has  been 
known  to  precipitate  pulmonary  oedema.  It  is  safer  to 
rel}'  upon  hot-air  baths  to  provoke  sweating.  Air  which 
is  heated  by  a  lamp  can  be  readily  conducted  under  bed- 


270  Functional  Inactivity  of  the  Kidneys. 

clothes  by  ii  bent  stove-pipe.  The  patient,  reclining 
upon  w  bed,  should  be  thickly  covered  with  bhmkets. 
The  desired  effect  will  be  attained  most  promptly  and 
most  perfectl}'  if  a  hot  drink  is  administered  when  the 
hot-air  bath  is  begun.  Sweating  may  be  advantageousl}" 
provoked  dail}',  or  even  oftener  in  extreme  cases.  I 
have  seen  patients  who  were  comatose,  and  occasionall}^ 
convulsed,  bronght  to  a  state  of  consciousness  by  this 
means.  In  two  fatal  cases  life  was  prolonged  for  several 
da3's  and  periods  of  consciousness  were  established, 
though  permanent  consciousness  could  not  be  restored. 
If  a  patient  is  very  oedematous  and  is  suffering  from 
chronic  unemia  sweating  must  be  resorted  to  with  care, 
for  it  has  been  known  to  provoke  acute  uraemia.  This 
is  due  to  the  sudden  re-absorption  by  the  blood  of 
oedematous  fluid  which  held  in  solution  ursemic  poison. 
The  re-absorption  was  provoked  by  the  elimination  of 
the  blood's  water  through  the  sweat-glands.  Under 
such  circumstances  only  moderate  sweating  should  be 
produced,  or  the  oedematous  fluid  should  be  first  with- 
drawn through  incisions  at  the  ankles.  (See  page  293.) 
While  elimination  of  the  uraemic  poison  can  be  most 
certainl}'  and  most  rapidly  and  perfectly'  accomplished 
b}^  the  skin,  it  can  be  helped  b\'  catharsis  and  diuresis. 
The  cathartics  which  will  accom[)lish  the  most  good 
produce  copious  liquid  stools.  If  frequentl}"  employed, 
they  ma}^  provoke  a  catarrhal  inflammtition  of  the  bowels 
or  cause  great  weakness.  They  are  best  employed 
occasional!}'  as  an  adjuvant  to  diaphoresis,  and  in  per- 
sons who  are  fairl}^  robust.  Salts  may  be  administered 
in  a  concentrated  solution  with  excellent  effect.  For 
instance,  if  30  grammes  (1  ounce)  of  Rochelle  salts  or 
magnesia  sulpliate,  dissolved  in  60  cubic  centimetres 
(2  ounces')  of  water,  is  administered  when  a  patient  first 


Uraemia.  2T1 

awakens  after  a  night's  sleep,  and  if  no  more  water  or 
fluids  are  drunk  for  some  time,  several  ver}-  copious 
liquid  passages  will  be  i)roduced.  Elaterium  is  deserv- 
edly a  favorite  liydragogue  cathartic.  It  \\\\.\y  be  given 
in  doses  of  1  centigramme  {^  grain).  The  compound 
extract  of  colocjMith  may  be  used,  in  doses  of  from  2 
decigrammes  to  1  gramme  (3  to  15  grains).  Croton-oil 
is  also  efficacious  in  its  usual  dose  of  1  minim. 

Diuresis  sliould  always  be  attempted,  but  disappoint- 
ment often  results  from  the  attempt.  In  mild  chronic 
cases  sufficient  elimination  can  generally  be  thus  accom- 
plished to  relieve  the  S3'mptoms,  but  in  cases  of  greater 
intensit}'  diuretics  do  not  suffice.  They  are  frequentlj' 
useful  when,  hy  diaphoresis  or  catharsis,  the  symptoms 
have  been  removed,  and  it  is  desired  to  steadily  maintain 
a  moderate  increase  of  elimination  of  the  ur?emic  poison, 
that  it  may  not  again  accumulate  in  toxic  quantities. 
The  diuretics  oftenest  used  are  digitalis,  strophanthus, 
acetate  and  citrate  of  potassium,  ammonium,  or  lithium. 
These  are  often  well  given  in  combination.  They  must 
be  adapted  to  individual  cases,  for  they  ma}-  be  contra- 
indicated  in  certain  renal  diseases,  as  will  be  explainied 
later.  Digitalis  and  stroplianthus  produce  diuresis 
chiefly  by  suppl3'ing  to  the  kidney  more  blood  under 
higher  pressure,  so  that  filtration  of  the  blood's  water  is 
accelerated.  If  the  blood  is  cj^anotic  because  of  the 
feeble  action  of  the  heart,  and  therefore  the  renal  as 
well  as  all  other  tissues  are  acting  imperfectly  on  account 
of  insufficient  nourishment,  digitalis  will  help  diuresis 
by  strengthening  the  heart,  and  thus  promoting  a  better 
general  circulation.  Oxygenation,  tissue-nutrition,  and 
action  nre.  therefore,  improved. 

Potassium,  acetate,  citrate,  and  carbonate  increase 
the  fluid  of  the  urine,  but  also,  to  a  marked  extent,  the 


272  Functional  Inactivity  of  the  Kidneys. 

elimination  of  nric  ucid  and  extractives  like  kreatin  and 
kreatinin.  The  citrate  of  potassinm  can  be  administered 
in  the  most  agreeable  form.  Two  cnbic  centimetres  (a 
^  drachm)  of  it  and  the  carbonate  can  be  mixed  with  a 
small  glass  of  lemonade  and  drunk  while  effervescing. 
The  acetate  is  eqnall}^  efficacious,  but  not  so  agreeable  to 
take.  The  value  of  water  as  a  diuretic  must  not  be  for- 
gotten. It  can  be  administered  freely  in  all  ursemic  cases. 
Life  can  sometimes  be  saved  by  subduing  nrsemic 
convulsions  by  complete  anaesthesia  with  chloroform, 
ether,  chloral,  or  morphia.  Many  cases  end  fatall}-  be- 
cause the  convulsions  stop  respiration,  or  impede  and 
weaken  the  circulation.  By  preventing  the  convulsions 
such  a  result  may  be  avoided,  and  time  ma}'  be  gained 
in  which  by  diaphoresis  and  catharsis  the  ur?emic  poison 
can  be  eliminated.  It  is  usually  best  to  check  the  con- 
vulsion b}'  inhalations  of  chloroform,  ether,  or  by  hypo- 
dermatics of  morphia.  After  convulsive  movements 
cease,  and  before  new  ones  are  excited,  a  large  dose  of 
chloral,  2  grammes  (30  grains),  should  be  administered 
to  prevent  their  recurrence.  If  this  is  successfully  ac- 
complished, as  the  effect  of  the  chloral  subsides  a 
smaller  dose  must  be  given,  and  the  drug  repeated  in 
successiveh'  smaller  doses  until  the  ura?mic  poison  is 
eliminated  and  its  re-nccumulation  prevented.  Opiates 
retard  the  elimination  of  nitrogenous  waste,  and,  there- 
fore, in  renal  diseases,  cannot  be  steadilj'  used  with 
safet3^  But  the}'  can  be  used  temporarily  to  subdue 
convulsions  when  diaphoretics,  cathartics,  and  diuretics 
are  simultaneoush'  emplo3'ed. 

Individual  cases  may  require  the  use  of  cardiac 
stimulants,  such  as  ammonia  or  camphor;  or  tonics, 
such  as  digitalis.  Other  com[)lications  in  particular 
cases  may  also  require  special  treatment. 


Ursemia.  273 

Prognosis.  —  Ursemia  is  a  dangerous  condition. 
Chronic  uriiemia  is  usually  readil}"  amenable  to  treat- 
ment. It  is  to  be  feared,  as  it  indicates  the  possibility 
of  an  acute  attack.  Acute  ursemia  is  very  fatal.  Braun 
asserts  that  30  per  cent,  of  cases  of  puerperal  convulsions 
are  fatal.  Urj\?mia  which  accompanies  acute  nephritis 
is  less  frequently  fatal  than  that  whicli  accompanies 
chronic  renal  inflammation.  The  immediate  prognosis 
of  uraimic  coma  without  convulsions  is  more  favorable 
than  with  them,  for  there  is  more  opportunity  of  effect- 
ing an  elimination  of  the  ursemic  poison.  But  such 
coma  oftenest  occurs  in  the  most  chronic  form  of  renal 
disease,  and,  therefore,  the  ultimate  prognosis  is  not 
good. 

12* 


DISEASES  OF  RENAL   CIRCULATION. 


CHAPTER  XXX. 
Passive  Congestion  of  the  Kidneys. 

Cause. — This  lesion  of  the  kidiie}'  nia}'  be  produced 
whenever  the  normiil  balance  between  venous  and  arte- 
rial blood  is  so  disturbed  that  the  veins  are  overfilled. 
Such  a  disturbance  results  from  cardiac  disease.  It  is 
often  est  associated  with  chronic  A^alvular  disease,  but 
may  be  with  degeneration  or  other  disease  of  the  heart's 
wall  or  of  the  pericardium,  wdiicli  makes  the  organ  weak. 
Passive  congestion  of  the  kidiievs  ma}^  also  be  the  re- 
sult of  obstruction  to  the  venous  circulation  in  the 
lungs,  or  between  the  kidneys  and  heart.  Of  lung  dis- 
eases, emph^'sema,  chronic  bronchitis,  interstitial  pneu- 
monia, and  more  rareh^  phthisis  and  chronic  pleurnl  dis- 
eases may  produce  passive  renal  congestion.  Cirrhosis, 
or  tumors  of  the  liver,  may  cause  sufficient  obstruction 
to  the  venous  current  from  other  abdominal  organs  to 
the  heart  to  produce  an  engorgement  of  the  kidneys. 
Much  more  rarely  abdominal  tumors  and  the  pregnant 
womb  compress  the  inferior  vena  cava,  or  veins  from 
the  kidneys  to  it,  and  cause  renal  congestion.  Throm- 
bosis of  the  renal  veins  or  vena  cava  is  a  very  rare 
cause  of  the  lesion. 

Anatomy. — The  anatomical  changes  in  the  kidney, 
when  it  is  passivel}^  engorged,  vary  somewhat  with  the 
rapidity  of  their  development.  As  usually  observed,  the 
kidne}'  is  enlarged,  especiall3'  by  congestion  of  the  cortex. 
If  the  couirestion  develop  very  slowly  the  organ  may 
(274) 


Passive  Congestion  of  the  Kidneys.  275 

be  little  or  not  at  all  swollen,  and,  if  it  is  rapidly  devel- 
oped to  a  considerable  degree,  it  may  be  greatly  en- 
larged. The  color  is  characteristically  dark  brown  or 
purplish.  The  stellate  veins  are  very  plainly  visible  be- 
cause distended.  Whenever  the  congestion  is  consid- 
erable, haemorrhages,  usually  minute,  are  observable ; 
but  if  the  lesion  develop  very  slowly  the  organ  will 
not  be  so  dark,  and  no  h{-emorrhages  will  be  discovera- 
ble. If  it  is  very  chronic  the  kidne}'-  becomes  paler, 
smnller,  (irmer,  the  surface  roughened,  and  the  capsule 
adherent  in  places.  Ordinarilj^  the  kidnej'S  are  firm, 
elastic,  smooth,  and  the  capsule  can  be  readilj^  stripped 
from  the  cortex.  When  a  section  is  made  through  the 
organs,  the  cut  surftice  is  characteristically  purplish 
in  color,  but  the  glomeruli  can  be  seen  with  unusual 
distinctness,  as  red  dots  which  are  arranged  in  rows. 
The  medulla  has  a  striated  appearance,  which  is 
plainest  where  congestion  is  the  deepest.  The  striation 
is  due  to  the  venous  distension.  In  tire  more  chronic 
cases,  when  the  kidney's  surface  is  paler,  the  cut  surface 
is  also. 

Under  the  microscope  the  veins  and  capillaries  are 
seen  to  be  stretched  b}-  the  blood-cells.  Often  small 
haemorrhages  into  the  glomeruli  or  tubules  can  be  found, 
or  the  site  of  former  haemorrhages  can  be  identified  by 
the  brownish  pigment-granules  that  may  be  seen  in  the 
tubules,  or  epithelial  or  connective-tissue  cells.  More 
rarely  black  melanin  cnsts  are  observable,  which  have 
been  formed  of  the  modified  blood-pigment.  The 
glomeruli  are  sometimes  a  little  enlarged.  In  very 
chronic  cases,  when  the  kidneys  have  contracted,  patches 
of  fibrous  .tissue  can  be  found  here  and  there,  especiall}^ 
just  beneath  and  usually  adherent  to  the  cnpsules.  In 
these  areas  the  glomeruli  are  often  contracted,  fibrous, 


276  Diseases  of  Renal  Circulation. 

or  homogeneous  and  h3'tiline.  The  tubules  are  obliter- 
uted  or  com[)ressed. 

The  epithelial  cells  ma}^  appear  nearly  normal,  but 
the^'  are  often  in  places,  and  sometimes  extensively, 
large  and  granular,  or  contain  fat-droplets,  or  are  partly 
disintegrated.  When  enlarged  they  will  nearly  fill  the 
tubules.  In  the  latter  hyaline  casts  are  occasionall}' 
observable,  or  a  few  red  corpuscles,  and,  less  frequently, 
epithelial  cells.  The  walls  of  the  blood-vessels  are 
usuall}'  thickened. 

Tlie  fibrous  patches  are  probabl}^  due  to  interstitial 
inflammation  which  arises  about  the  blood-vessels  or 
spreads  from  venous  and  arterial  walls.  It  causes  com- 
pression of  the  tubules  and  consequent  atrophj'  and 
destruction  of  them. 

Symptoms. — The  symptoms  of  passive  engorgement 
of  the  kidne^^s  are  superimposed  upon,  and  associated 
with,  those  of  a  primary  disease.  For  instance,  the 
usual  features  of  mitral-valve  disease  of  the  heart 
may  be  accompanied  with  the  evidences  of  renal  engorge- 
ment. In  such  cases  usuall}'  the  pulse  and  heart  are 
weak,  and  there  is  general  oedema  and  dyspnoea.  The 
characteristic  signs  of  the  lesion  must  be  sought  for  in 
the  urine.  General I3'  the  heart-lesion  or  other  primary 
atfection  and  its  symptoms  exist  for  weeks,  or  months, 
or  even  years,  before  the  kidneys  are  serioush^  involved. 

The  urine  is  usuall}'  diminished  in  amount.  It  is 
strongly  acid  in  reaction.  Its  si)ecific  gravity  is  from 
1025  to  1035.  It  is  deeper  colored  than  is  normal.  A 
relative  and  sometimes  an  absolute  excess  of  urates  and 
uric  acid  must  be  expected.  Uric-acid  crystals  are 
frequently  deposited  in  the  urine  when  it  stands.  If, 
as  is  usual,  a  urinar}'  sediment  exist,  it  is  composed 
of  these  chemical  substances.     Often  a  few  blood-cor- 


Passive  Congestion  of  the  Kidneys.  27 T 

puscles  can  be  found  in  it,  and  a  few  ii^aline  or,  rarely, 
granular  or  blood  casts.  Epithelial  cells  from  the  kid- 
ney are  also  rarelj^  observed.  Oil  droplets  or  granules 
must  not  be  expected.  The  urine  usually  contains  a 
small  amount  of  albumen, — a  fifth  of  1  per  cent,  or  less. 

Uriemic  symptoms  are  rare,  for  the  comparativel}' 
normal  condition  of  the  renal  epithelium  enables  it  to 
eliminiite  nitro2,enous  matters.  Renal  conoestion  is 
frequentl}'  transformed  into  nephritis,  for  it  predisposes 
to  inflammation  of  the  organ. 

Death  commonly-  results  from  the  primary  disease, 
and  is  not  produced  by  the  renal  lesion.  The  renal 
complication  is  significant  of  the  gravity  of  the  primary 
trouble.  Renal  engorgement  ma}'  occur  repeatedly  in 
the  same  case  during  a  period  of  several  years,  or,  after 
developing,  may  persist.  The  duration  of  the  diseases 
which  produce  this  renal  lesion  is  uncertain  and  very 
variable.  The  diseases  are  alwaj's,  sooner  or  later,  fatal. 
Whenever  a  cause  for  passive  engorgement  of  viscera 
exists,  the  urine  should  be  examined.  If  there  is  evi- 
dence of  a  heart  lesion  and  engorgement  of  the  lungs 
or  liver,  and  the  urine  presents  the  featnres  just  de- 
scribed, a  direct  and  positive  diagnosis  can  be  made.  It 
must  be  differentiated  from  acute  and  chronic  nephritis. 
(See  page  288.) 

Treatment. — Passive  renal  congestion  requires  no 
peculiar  treatment.  Its  cause  must  be  removed.  If,  as 
is  oftenest  the  case,  a  feeble  heart  canse  it,  the  latter 
must  be  relieved  of  unnecessar}'  work  b}-  bodily  rest. 
In  some  cases,  after  a  few  daj^s  spent  in  Led,  the  symp- 
toms of  renal  congestion  will  disappear.  Strophanthus, 
digitalis,  and  similar  heart  tonics  are  indicated.  The 
treatment  must  be  that  which  we  have  already  described 
as  essential  for  weak  heart.     (See  pages  206,  222.) 


278  Diseases  of  Renal  Circulation. 

Nephritis  must  be  guarded  against.  Cold,  damp, 
and  changeable  weather  should  be  avoided.  The  bod^- 
should  be  protected  from  sudden  atmospheric  changes 
by  clothing  it  with  woolen  under-garments. 

If  the  quantit}'  of  albumen  in  the  urine  is  for  this 
disease  considerable  and  the  quantitv^  of  urine  small, 
foods,  beverages,  and  drugs  that  irritate  the  kidne3S 
should  be  avoided.  Under  such  circumstances,  albu- 
mens should  be  taken  sparingl}-  ;  alcoholics  should  not 
be  used  ;  and  cubebs,  turpentine,  and  other  drugs  that 
are  renal  Irritants  are  contra-indicated.  As  a  rule,  the 
diet  should  be  generous  and  highly  nutritious,  in  order 
to  maintain  as  good  cardiac  vigor  and  general  health 
as  is  possible. 


RENAL  INFLAMMATIONS. 


CHAPTER  XXXI. 

Acute  Nephritis. 

Causes. — Acute  nephritis  is  especially  apt  to  com- 
plicate the  eruptive  fevers,  infectious  and  septic  dis- 
eases. Of  these  maladies,  scarlet  fever  and  diphtheria 
are  oftenest  accompanied  hy  nephritis.  It  has  been 
supposed  that  in  such  cases  micro-organisms  which 
caused  the  primary  ailment  were  also  the  cause  of  the 
nephritis.  This  has  not  been  proven.  It  seems  quite 
as  probable  that  irritating  chemicals  which  are  formed 
under  conditions  of  malnutrition  that  accompany  the 
primaiT  disease  are  the  cause  of  the  renal  inflammation. 
It  must  be  acknowledged  that  mau}^  observers  have 
found  micro-organisms  of  different  kinds  in  diseased 
kidnej'S.  Their  presence  where  the  inflammation  was 
most  intense  suggests  their  causative  relation  to  -it. 
But  more  numerous  observations  are  needed  to  confirm 
the  scattered  ones  already  made.  The  kidneys  appear 
capable  of  eliminating  some  micro-organisms  in  small 
numbers,  but  if  they  are  required  to  attempt  the  elimi- 
nation of  many  the  interstitial  tissues  are  found  filled 
with  them,  or  obstructing  clumps  of  them  are  seen  in 
the  tubules.  If  such  collections  take  place  in  man,  as 
may  occur  in  animals  experimented  upon,  they  maj'- 
sometimes  provoke  an  inflammation.  Such  substances 
as  cantharides,  turpentine,  salicylic  and  carbolic  acids, 
when  ingested,  are  eliminated  hy  the  kidneys,  and  will 
cause  nephritis  when  absorbed  into  the  blood  in  large 

(279) 


280  Renal  Inflammationit. 

amounts.  Cases  of  acute  nephritis,  the  result  of  tur- 
})entine  poisoning,  are  not  very  uncommon.  I  have 
observed  them  oftenest  during  the  summer,  in  painters 
using  turpentine  in  close  and  overheated  rooms.  Ex- 
tensive burns  of  the  skin  have  produced  acute  nephritis, 
but  in  what  wa}-  is  undecided.  It  ma}-  be  that  the 
kidneys  are  overworked,  as  they  attempt  to  vicariouslj- 
perform  the  eliminative  functions  of  the  skin,  or  that 
the\'  are  irritated  b3'  substances  which  should  be  elimi- 
nated through  the  skin,  and  which,  because  of  injurv 
to  the  latter,  accumulate  in  the  blood.  The  causation 
of  many  cases  cannot  be  satisfactorily  explained. 

The}'  often  occur  after  sudden  exposure  to  cold  and 
dampness.  Acute  nephritis,  therefore,  is  observed  most 
frequenth'  in  seasons  and  in  climates  that  ai-e  character- 
ized by  changeabilit}"  of  temperature,  with  moisture.  It 
has  been  claimed  tliat  at  times  nephritis  is  epidemic. 
The  cases  that  have  been  collated  are,  however,  too  few 
to  prove  its  epidemicity. 

Acute  nephritis  may  occur  at  an}^  age,  but  is  oftenest 
observed  in  early  adult  life.  Men  are  oftener  subject 
to  it  than  women,  if  we  do  not  take  into  consideration 
puerperal  nephritis. 

Albuminuria  and  other  urinar}"  changes  indicative 
of  renal  disease  are  of  common  occurrence  in  the  course 
of  continued  fevers  like  typhoid.  The  evidence  of  renal 
trouble  is  usuall}^  slight,  reaches'its  maximum  when  the 
fever  is  most  severe,  and  subsides  with  it.  These  are 
cases  of  acute  degeneration  or  cloud}'  swelling,  ratiier 
than  of  true  nephritis.  Occasional!}',  some  nephritis 
accompanies  the  degeneration. 

Anatomy. — The  pathological  chnnges  characterizing 
acute  nephritis,  as  might  be  expected  from  the  varying 
etiology,  are  not  uniform.     An  affected  kidney  may  re- 


Acute  Nephritis.   '  281 

main  normal  in  size,  but  usually  it  is  more  or  less 
enlarged.  In  some  cases  it  is  greatl}'  swollen,  cliiefly 
because  of  an  interstitial  serous  exndnte.  The  surface 
of  the  kidney  is  smooth,  and  the  capsule  will  strip  from 
the  cortex  with  ease.  The  color  of  the  surface  varies 
from  red  to  pearl}-  yellow,  or  is  mottled  red  and  3ellow. 
When  the  organs  are  enlarged  the  incrensed  size  is  due 
to  thickening  of  the  cortex,  for  the  pyrnniidal  part  of 
the  organ  remains  unchanged  in  size.  The  red  kidneys 
are  usunlly  of  a  dark  hue.  and  so  much  congested  tliat 
blood  AY  ill  drip  from  their  cut  surface.  The  glomeruli  are 
often  prominent  as  red  dots.  The  mottIe<l  form  contains 
less  blood.  The  cortex  in  the  pale  form  is  in  places — and 
sometimes  diffusely — whiter  than  is  normal,  although 
the  pyramids  are  dark-red,  and  often  appear  striated. 
The  lighter  color  of  the  cortex  is  due  to  fatt}'  degen- 
eration. 

The  microscope  demonstrates  that  the  focus  of  the 
lesion  varies  in  individual  cases.  Sometimes  the  glom- 
eruli and  their  neighborhood  onh^  seem  inflamed  ;  some- 
times an  interstitial  serous  exudation,  with  some  degen- 
eration of  the  connective-tissue  cells,  is  the  important 
change;  in  other  cases  the  e[)ithelium  of  the  tubules  is 
chiefly  aflfected.  In  the  cases  of  acute  albuminuria  in 
which  there  is  the  least  renal  change  the  lesion  is  a 
degeneration  of  the  epithelium  of  the  tubules.  To  the 
unaided  eye  the  kidneys  appear  unchanged,  or  onlj'  a 
trifle  large  and  i)ale.  Under  the  microscope  the  epithe- 
lial cells  are  seen  to  be  swollen,  so  that  thev  nearl}-  close 
the  tubules  ;  they  are  more  granular  than  natural,  and 
may  have  no  nucleus,  or  in  them  it  is  obscured.  The 
interstitial  tissues,  glomeruli,  and  blood-vessels  may 
remain  unchanged.  Such  lesions  are  oftenest  observed 
in  cases  of  typhoid  fever,  diphtheria,  or  other  fevers  of 

M2 


282  ^enal  tnfiammations. 

an  asthenic  ty[)e.  They  are  rather  due  to  acute  degen- 
eration than  to  inflanmiMtion.  The  condition  is  denom- 
inated cloudy  swelling.  Fatt}'  degeneration  ma}'  grow 
out  of  it,  or  it  may  be  associated  with  true  inflammation. 
Fatty  degeneration  ma}'  occur  acuteh',  for  it  need  not 
develop  from  cloudy  swelling.  It  is  oftenest  the  result 
of  infectious  diseases,  or  anaemia,  or  phosphorus  poison- 
ing. When  fatt}'  degeneration  exists  the  epithelium  of 
the  tubules  and  glomeruli  are  not  only  granular,  but  oil- 
droplets  are  demonstrable  in  them.  Cells  that  are  fat- 
tily  degenerated  oftener  disintegrate  than  those  cloudily 
swollen.  If  inflammation  as  well  as  degeneration  exist, 
inflammatory  exudates  will  also  be  observed.  Degen- 
erative changes  ma}'  precede  inflammatory  ones,  but 
quite  as  often  follow  them.  When  inflammation  exists 
some  degeneration  can  also  be  demonstrated.  In  certain 
cases  the  kidneys  are  greatly  enlarged  and  softened.  In 
them  the  interstitial  lymph-spaces  are  usually  distended 
with  a  serous  exudate.  A  few  migrated  round-cells 
may  be  found  about  the  vessels,  but  the  inflammatory 
exudate  is  chiefly  serous.  In  specimens  preserved  in 
alcohol  small  clots  of  albumen  can  be  seen  within  the 
glomeruli  or  in  the  lymph-spaces.  The  renal  epithelium 
is  usually  granular  and  degenerated. 

In  other  cases  a  cellular  exudate  can  be  found  about 
the  interlobular  vessels.  The  tubular  epithelium  is 
usually  partly  degenerated,  and  often  extensively  cast 
oflf.  The  swollen  cells  or  their  detritus  fill  some 
tubules ;  the  calibre  of  others  is  increased  by  the  loss 
of  epithelium. 

In  other  cases,  oftenest  in  those  which  follow  scar- 
latina and  poisoning  by  terebinthines,  the  glomeruli  are 
chiefly  involved.  The  capsule  of  Bowman  is  usually 
thickened,  the  nuclei  in  the  capillary  tuft  nre  increased, 


Acute  Nephritis.  283 

and  the  tuft  is  enlarged.  Round-cell  infiltration  can 
be  seen  about  tlie  glomeruli.  The  tuft  of  capillaries, 
instead  of  being  clianged,  as  just  described,  ma}^  become 
liomogeneous  and  vitreous  from  h3aline  degeneration. 
Small  hsemorrliages  are  frequent  in  and  about  the  glom- 
eruli. In  all  forms  of  acute  nephritis  minute  haemor- 
rhages are  common,  and  they  may  occur  anywhere  in 
the  cortex. 

We  often  find  glomeruli,  tubules,  and  interstitial 
tissues  all  affected,  but  in  varying  degrees.  In  some 
cases  epithelial  desquamation  from  the  tubules  is  very 
moderate,  in  others  very  extensive.  So  the  amount  of 
haemorrhage  varies,  but  it  is  present  to  some  extent  in 
almost  every  case  of  acute  nephritis.  Some  of  the 
blood-corpuscles  find  their  way  into  the  tubules  and  are 
eliminated  with  the  urine.  It  must  not  be  supposed 
that  all  the  glomeruli  are  equally,  or  even  at  all, 
affected.  Usuall}^,  some  remain  perfectlj'  normal,  and 
continue  to  imperfectl}'  perform  the  functions  of  the 
whole  organ.  When  the  kidne}'  is  congested  the  vessels, 
especially  the  interlobular  ones,  are  distended  with 
blood.  The  medulla  of  the  kidney  is  usuall}'  little  mod- 
ified. Sometimes,  when  degeneration  is  extensive  or 
congestion  very  great,  it  may  be  affected  slightly,  as  the 
cortex  is  extensively. 

Acute  degeneration  and  acute  inflammation  prevent 
the  physiological  action  of  the  kidne3\  Tiiese  lesions 
cause,  almost  without  exception,  albuminuri.-i.  What  is 
much  more  important,  the  separation  of  waste  nitrog- 
enous matter  from  the  blood,  and  its  elimination 
through  the  urinary  channels,  is  lessened  or  prevented. 
Therefore,  the  liability  to  surcharge  the  blood  with  these 
products  of  waste,  and  the  danger  of  uraemia  because  of 
them,  is  considerable. 


284  Jienal  Itr/iammations. 

Diuresis  is  interfered  -with  by  tlie  vurious  changes 
which  may  occur  in  the  glomeruli,  and  also  by  obstruc- 
tions in  the  tubules,  which  may  be  formed  of  desqua- 
mated cells  or  thiir  detritus  or  of  hj'aline  casts. 

Symjjtoms. — The  disease  may  devehjp  insidiousl}-, 
and  not  be  suspected  until  it  produces  striking  symp- 
toms, such  as  oedema.  The  milder  cases,  especially 
tliose  that  complicate  fevers,  ma}'  not  Ite  suspected 
unless  the  urine  is  frequently'  examined.  A  di.'ignosis 
can  be  made  from  the  changes  observed  in  the  urine, 
but  in  all  moderately  severe  cases  there  are  other  symp- 
toms that  are  characteristic.  In  the  cases  which  de- 
velop insidiously-,  oedema  is  usually  the  first  s^'mptom 
to  attract  attention,  though  some  })atients  notice  changes 
in  the  frequency  of  urination  or  in  the  a[)pearance  of  the 
urine.  In  a  smaller  proportion  of  cases  a  chill  announces 
the  onset  of  the  attack.  This  is  followed  by  a  rise  of 
temperature  which  will  last  a  few  days.  Headache 
usuall}'  accompanies  the  onset.  Sometimes,  a  dull 
achino-  is  felt  in  the  small  of  the  back,  but  oftener  back- 
ache  is  absent.  Tiie  urine  is  observed  to  be  scant,  tur- 
bid, and  deeply  colored.  The  skin  rapidly  grows  pale, 
and,  as  a  rule,  general  oedema  is  noticeable  after  the 
first  two  or  three  days.  These  constitute  the  most 
striking  symptoms  of  the  sharplj^-acute  cases.  Very 
man}',  however,  run  an  apyretic  course.  General  oedema 
exists,  as  a  rule,  but  in  mild  cases  it  may  be  absent,  and 
is  usually  in  those  cases  that  are  acute  degenerations 
rather  than  inflammations.  The  oedema  is  generally 
first  observed  about  the  ankles,  or  simultaneously  about 
the  feet  and  in  the  eyelid^.  At  times  patients  become 
ra))idly  and  excessively  oedematous,  so  that  feet,  hands, 
face,  and  body  are  greatly  swollen.  The  eyelids  rarely 
are  so  filled  with  oedematous  fluid  that  they  cannot  be 


Acute  Nephritis.  285 

opened,  and  are  distended  beyond  the  forehead.  Usually 
dependent  parts  only  are  much  oedematous.  Tlie  feet, 
the  penis,  scrotum,  and,  less  extensively,  the  hands,  are 
oftenest  affected. 

We  must  search  for  the  pathognomonic  symptoms  in 
the  urine.  It  is  diminished  in  amount,  and  in  extreme 
cases  is  almost  suppressed.  It  will  measure  from  125 
to  500  cubic  centimetres  (4  to  16  ounces)  in  twenty -four 
hours.  It  is  reddish  or  brownisli  red  nnd  turbid.  Some- 
times it  is  blood3\  As  a  rule,  blood-corpuscles  can  be 
found  in  it  in  varjing  numbers,  and  often  are  very 
abundant.  Its  specific  gravity  is  increased  to  from 
1030  to  1040.  It  is  acid  in  reaction.  Albumen  is  mod- 
erately, and,  may  be,  ver}'  abundant  in  it.  There  is 
usuall}'  from  0.5  to  1  per  cent,  of  it,  and  there  may  be 
as  much  as  3  per  cent.  In  individual  samples  of  urine 
there  ma}^  be  an  excess  of  urea,  but  during  twenty-four 
hours  its  amount  is  from  25  to  50  per  cent,  less  than 
normal.  The  other  solids  are  also  diminished.  If 
allowed  to  stand,  a  sediment  is  deposited  in  the  urine. 
In  some  cases  it  is  composed  chiefly  of  red  blood-cells, 
in  others  of  epithelium,  but  in  most  cases  of  both  these 
elements,  together  with  casts  and  urates.  The  blood- 
cells  often  are  attached  to  casts,  and  sometimes  cover 
them,  but  are  most  abundant  as  free  cells.  Clots  do 
not  form  in  the  urine  even  when  haemorrhage  is  copious, 
providing  it  is  from  the  kidney.  Epithelial  cells  are 
usually  observed  in  large  numbers,  and  are  recognized 
because  the}'  are  small,  cuboidnl,  or  rudely  rounded,  and 
contain  large  nuclei.  If  the  disease  has  lasted  long,  fat- 
drops  can  often  be  seen  in  them.  Earlier,  they  are  granu- 
lar. While  they  are  most  abundant  as  free  cells,  they  fre- 
quently are  adherent  to  hyaline  casts,  and  more  rarel}'  are 
adherent  to  one  another,  forming  hollow  tubes.     Casts 


280  Renal  Inflammations. 

of  all  kinds  are  observable  in  acute  nephritis.  Usuall}', 
particular  kinds  predominate  in  individual  cases.  Blood 
and  epithelial  casts,  such  as  have  just  been  described, 
are  often  seen.  Grauular  and  hyaline  ones  are  also 
common.  Long,  narrow  casts  are  usually  formed  in  the 
early  stage  of  the  disease,  and  short,  broad  ones  later. 
Besides  these  formed  elements,  granular  matter,  which 
is  the  detritus  of  disintegrated  cells,  is  usually  abun- 
dant. Crystals  of  uric  acid,  urates,  and  oxalate  of  lime 
often  compose  part  of  the  sediment.  Oil-drops  are 
rarely  seen  in  the  urine  of  acute  cases.  Micturition  is 
frequent  and  accompanied  b}'  painful  straining. 

The  anatomical  changes  in  the  kiduey  readily  account 
for  the  abnormal  character  of  the  urine.  Hsematuria  is 
due  parti}'  to  haemorrhages  in  the  kidney,  and  partly  to 
the  abnormal  permeability  of  the  renal  vessels,  es[)ecially 
in  the  glomeruli.  The  changes  in  the  glomerular  epithe- 
lium and  capillaries  permit  the  escape  of  albumen  and 
lessen  diuresis.  The  obstruction  to  the  tubules  by 
casts,  epithelium,  and  its  detritus  still  more  interfere 
with  a  copious  flow  of  urine.  The  degeneration  aud 
desquamation  of  the  renal  epithelium  account  for  the 
diminished  exci'etion  of  urea  and  other  urinary-  solids. 

The  loss  of  blood  by  the  kidne3's  leads  to  auiemia, 
which  in  turn  produces  the  waxy  whiteness  of  the  skin 
characteristic  of  these  cases.  Not  only  does  the  blood 
lose  many  of  its  cells,  but  it  is  poor  in  albumen,  and 
its  specific  gravity  is  lowered.  Urea,  uric  acid,  and 
other  excrementitious  matters  ac(;umulate  in  it.  The 
heart  is  rarely  liypertropliied  in  acute  nephritis,  but  it 
is  sometimes  acutely  dilated.  Pericarditis  is  an  occa- 
sional complication.  The  blood  tension  in  the  arteries 
is  usually  increased.  The  pulsc-inte  vnries  with  bodily 
temperature,  or  it  may  be  quickened  if  the  heart 'is  di- 


Acute  Nephritis.  281 

lated  and  weak.  Bronchitis  is  a  frequent  complication. 
Pleuris>'  occurs  often  and  tends  to  become  purulent. 
Pneumonia  is  an  occasional  complication  and  an  es- 
pecially fatal  one.  Pleural  and  pericardial  drops}^,  as 
well  as  ascites,  are  accompaniments  of  general  drops}^, 
and  may  be  the  immediate  cause  of  death.  Uraeraic 
asthma  is  another  respiratory  complication  that  is  some- 
times observed. 

Appetite  is  usually  much  diminished  or  almost 
wanting*.  Nausea  and  vomiting  occur  occasionally.  At 
first  they  probably  are  of  reflex  origin,  and  due  to  renal 
congestion  and  irritation.  Later,  the}'  may  be  uraemic 
symptoms.  The  bowels  are  usuall}^  constipated,  but 
occasionall}'  there  is  diarrhoea,  which  may  be  due  to 
intestinal  oedema  or  to  a  vicarious  elimination  of  abnor- 
mal matters  from  the  blood.  Uraemia  is  especially-  apt 
to  occur  in  this  disease.  Transient  uraemic  amaurosis 
occurs  occasionall>\  Retinal  haemorrhage,  nose-bleed, 
or  other  ha^morrhnges  than  haematuria  are  not  common. 
Life  is  chiefly  endangered  b}-  uraemia  and  various  com- 
plications, such  as  pneumonia,  pleuris}^,  pericarditis, 
dropsy  of  the  serous  sacs  within  the  thorax,  or  oedema 
of  the  lungs  or  of  the  glottis. 

Relapses  may  occur  repeatedly  after  convalescence  is 
apparently  established.  Li  this  way  the  course  of 
individual  cases  ma}^  be  much  protracted.  The  duration 
of  mild  cases  is  from  one  to  two  weeks,  but  other  cases 
may  be  protracted  from  four  to  twelve  weeks.  A  small 
proportion  of  acute  cases  become  chronic. 

Uraemia  develops  from  failure  to  properlj-  eliminate 
waste  matter  b}'  the  kidneys.  It  must  be  suspected 
whenever  the  urine  is  grently  diminished  in  amount,  and 
especially  when  the  total  nitrogenous  waste  for  twenty- 
four  hours  is  greatly  lessened.      These   are  signs  of 


288  Renal  Injiammations. 

gravity.  The  iimount  of  albuinen  voided  is  not  signifi- 
cant of  the  severity'  of  the  disease  or  its  dangerousness. 
When  improvement  begins,  the  urine  grows  more 
abundant,  hsematuria  ceases,  the  albumen  lessens,  casts 
are  less  numerous,  shorter,  and  more  broken.  If  there 
has  been  much  drops}',  and  if  it  is  being  absorbed  during 
convalescence,  the  urine  will  become  unusually  copious, 
and  its  specific  gravity  ma}-  Ije  abnormall}'  lowered. 

Diagnosis. — A  diagnosis  is  usually  not  diflflcult,  aiid 
may  be  made  from  a  urinalysis.  In  mild  cases  there 
may  be  no  signs  of  the  disease,  other  than  those  that  are 
discoverable  in  the  urine.  It  ma}^  otherwise  be  wholly 
masked  by  a  primary  disease.  But  in  some  cases  the 
general  symptoms  are  quite  as  pronounced  as  the 
urinary  ones. 

A  direct  diagnosis  can  be  made  positively  when 
there  is  associated  with  the  characteristic  urinar}' 
changes  general  oedema,  rapidly  developed  anaemia,  and 
a  history  of  sudden  onset  and  of  no  previous  attacks  of 
a  similar  kind.  Acute  nephritis  must  sometimes  be 
differentiated  from  chronic  venous  hyperiemia  and  acute 
exacerbations  of  chronic  parenchymatous  nephritis. 
From  the  former  it  can  be  distinguished  by  the  larger 
amount  of  albumen  and  a  greater  number  of  red  blood- 
cells  in  the  urine,  and  b}'  the  development  of  cedema, 
which  usuall}'  is  as  quickl}'  observed  about  the  e3'elids 
as  in  the  feet.  When  passive  congestion  of  the  kidne3's 
exists,  there  must  also  be  one  of  its  essential  causes. 
When  in  the  course  of  chronic  parenchj-matous  nephritis 
acute  exacerbations  occur,  there  are  superimposed  upon 
the  symptoms  of  the  chronic  malad}'  those  of  the  acute. 
The  urine  ma}'  be  almost  undistinguishable  from  that 
of  acute  nephritis.  Usually,  however,  oil-drops  and 
fatty  epithelial  cells   or    fatt}'   casts   are   abundant.     A 


Acute  Nephritis.  289 

diagnosis  must,  however,  be  chiefly  based  on  the  history 
of  prior  attacks  of  the  same  kind,  or  at  least  of  oedema 
and  other  sym[)toms  of  ciironic  nephritis. 

IVeatment. — Tlie  indications  for  treatment  are,  first, 
to  give  the  kidneys,  as  fiir  as  possible,  a  rest ;  second, 
to  limit  congestion  ;  tliiid,  to  remove  obstructions  in 
the  renal  tubules;  fourth,  to  guard  against  or  mitigate 
com[)licMtions  or  sequela^. 

To  meet  the  first  indications,  those  who  suffer  from 
acute  nephritis  should  remain  in  bed,  for  exercise  will 
increase  nitrogenous  wMste,  and  therefore  its  elimina- 
tion, whicli  means  reunl  work.  They  should  live  upon 
a  non-nitrogenous  diet.  Tliis  last  requirement  must 
be  rigidly  adhered  to  only  in  the  most  severe  cases,  or 
when  uraemia  most  threatens.  But  in  all  cases  the  diet 
must  be  so  modified  that  it  will  contain  only  a  small 
amount  of  nitrogenous  matter.  Water-gruels  made  of 
arrowroot  or  barley-meal  may^atford  a  modicum  of  nour- 
ishment for  two  or  three  da3'S,  until  the  height  of  the 
attack  is  passed.  Fine  wheat-flour,  rice,  potatoes,  and 
turnips  are  additional  foods  that  contain  very  small 
amounts  of  nitrogen  or  vegetable  albumen.  Apples  and 
grapes  are  also  somewhnt  nutritious,  and  may  be  grate- 
ful as  condiments.  These  latter  nrticles  can  be  em- 
ployed in  the  less  severe  cases,  or  after  improvement  is 
established.  It  is  best  to  administer  nourishment  in 
moderate  amounts  and  often,  so  that  it  will  not  be  too 
long  undigested,  as  otherwise  it  may  irritate  the  ali- 
mentar}^  canal  b}'  feeding  gastric  or  intestinal  fermentn- 
tion.  In  the  periods  of  greatest  severity,  or  when 
uraemia  most  threatens,  even  milk  sIkmiUI  not  be  used, 
but  during  convalescence  it  is  particularl}'  wholesome, 
for  it  is  a  diuretic,  very  nutritious,  and  easily  digested. 
It  may  with  advantage,  at  this  time,  constitute  the  chief 

13    N 


290  Renal  Inflammations. 

element  of  diet.  When  a  normal  nitrogenous  elimina- 
tion b3'  the  kidneys  has  been  re-established,  other  albu- 
minous food  can  be  tried  with  caution.  The  fact  that 
gastric  juice  and  probabl}'  other  digestive  secretions  are 
lessened  in  nephritis  makes  it  necessar\'  to  guard  against 
filling  the  stomach  with  food,  but  enough  must  be  given 
to  maintain  nutrition. 

A  patient  should  remain  in  bed  until  oedema  has 
wholly  disappeared  and  urea  is  voided  in  normal  quanti- 
ties. Exercise  should  not  be  continued  if  by  it  the 
elimination  of  urine  and  nitrogenous  matter  is  lessened. 

To  limit  or  lessen  renal  congestion,  leeching  and  cup- 
ping are  often  emplo3'ed.  Although  unnecessar3'  in  tlie 
milder  cases,  the}'  are  especiallj'  indicated  in  those  in 
which  there  is  the  most  congestion  ;  those  in  which  the 
urine  is  scant,  very  blood}' ;  and  in  which  there  is 
backache. 

Cathartics  are  also  em])loyed  to  deplete  the  rennl 
vessels.  Aperients,  such  as  Rochelle  salts  and  magnesia 
sulphate,  are  the  best.  In  acute  nephritis,  and  especially 
at  first,  catharsis  must  not  be  carried  so  far  as  to  in- 
crease a  patient's  weakness.  It  is  usuall}'  sufficient  to 
maintain  the  stools  soft,  and  defecation  should  take 
place  oidy  two  or  three  times  dail}^  A  small  glass  of 
Hunyadi  Janos  water,  a  little  of  liquid  citrate  of  mngnesia 
or  Carlsbad  salts,  taken  in  the  morning,  will  usually  ac- 
complish this.  If  the  urine  is  suddenly  almost  suppressed, 
a  few  liquid  stools  will  often  relieve  the  congestion 
which  causes  it,  and  should  be  provoked  unhesitatingi}-. 

it  goes  without  saying  that  drugs  n,nd  beverages, 
which  in  themselves  are  renal  irritnnts,  must  not  be 
used.  Among  these  are  all  alcoholic  beverages,  tea 
and  coffee,  terebinthins,  copaiba,  and  squills. 

The  obstructions  in  the  renal  tubules  are  composed 


Acute  A^ejyhritis.  291 

of  cells,  Ihe  gnimilai'  detritus  which  results  from  their 
dissolution,  niul  hyaline  sulisttuice.  Much  of  this  can  be^ 
washed  from  the  tubules  b}'  a  more  copious  flow  of 
urine.  The  hyaline  substance  has  been  shown  by  l*urdy 
to  be  soluble  in  alkaline  solutions;  therefore,  to  make 
the  tubules  patent,  the  urine  must  be  ke[)t  alkaline  ;uid 
must  be  Jibunchint. 

Digitalis  will  increase  the  general  blood-pressure, 
and  therefore  the  pressure  in  the  glomerular  tufts,  b}'' 
increasing  the  vigor  of  the  heart's  action  and  by  con- 
tracting the  arterioles.  This  will  cause  a  more  rapid 
filtration  of  water  from  the  blood  into  the  urinary  chan- 
nels in  cases  of  acute  nephritis.  The  quantity  of  urine 
is  decidedly  increased  by  this  drug.  Its  action  is  pref- 
erable to  that  of  strophanthus,  for  the  latter,  in  thera- 
peutic doses,  does  not  contract  the  arterioles.  The 
action  of  digitalis  upon  the  arterioles  is,  moreover, 
valuable,  since  it  lessens  hiemorrhage.  In  order  to 
render  the  urine  alkaline,  such  drugs  as  the  citrate  and 
acetate  of  potash  and  liquor  ammonii  acetatis  may  be 
used.  The  first  are  the  most  ngrecMble  to  tnke,  and  may 
be  employed  in  doses  of  from  2  to  4  grammes  (^  to  1 
di'achm),  repeated  every  two  to  four  hours,  as  may  be 
needed  to  keep  the  urine  alkaline.  Liquor  ammonii 
acetatis  may  be  given  in  doses  of  from  2  to  4  cubic 
centimetres  (i  to  1  drachm).  It  is  certiunly  true  that, 
under  the  influence  of  these  drugs,  casts  usually  become 
less  numerous  and  less  perfect  in  outline. 

The  diuretics  just  mentioned  are  useful  not  only  to 
keep  the  urinary  tubules  oi)en,  but  also  to  promote  a 
more  perfect  excretion  of  urinary  solids.  Digitalis 
heli)S  by  making  a  more  copious  flow  of  urine;  the 
potassium  salts  aid  b^-  increasing  the  oxidation  wMthin 
the  system  and  by  stimulating  the  renal  epithelium  to 


292  Renal  Inflammations. 

greater  fiiiietional  activit};.  Therefore,  larger  amounts 
of  urea  are  voided,  which  means  that  man^-  imperfectly 
oxidized  products  of  metabolishi  become  perfectly 
oxidized,  and  are  in  a  condition  for  eas}'  elimination. 
This  will  greatl}'  lessen  the  danger  of  uraemia.  Although 
lactose  and  glucose  are  often  very  efficacious  diuretics 
in  cardiac  affections,  the}'  are  not  so  in  renal  diseases. 
Indeed,  in  the  latter  diseases  they  sometimes  produce  no 
appreciable  diuresis.  Thej'  probabl}'  act  upon  the  renal' 
epithelium,  and,  if  it  is  not  intact,  tliey  are  inefficacious. 
In  my  own  experience  they  liave  proved  moderately 
efficient  in  some  mild  cases  of  chronic  nephritis,  but 
almost  useless  in  the  acute  disease.  Unfortunateh',  the 
epithelium  is  often  so  extensivel}'  desquamated  or  dis- 
eased that  these  drugs  are  able  to  promote  onl}'  a  very 
moderate  increase  of  urine,  urea,  etc.  We  must  depend, 
therefore,  u[)on  other  channels  to  eliminnte  the  poisonous 
effete  materials  that  ma}'  be  accumuhiting  in  the  system. 
The  skin  will  eliminate  the  largest  amount  of  such 
matter;  therefore,  diaphoresis  should  be  i)rovoked  enrh 
in  all  cases  in  which  the  amount  of  urinary  solids  voided 
daily  is  much  reduced.  (See  page  269.)  It  should  be 
repeated  for  a  few  minutes  daily,  or  every  second  or 
third  day,  according  as  the  kidneys  are  able  to  do  their 
work  more  or  less  w^ell.  Dinphoresis  must  be  resorted 
to  with  caution  whenever  there  is  much  oedema,  for,  by 
pi'ovoking  a  sudden  re-absor[)tion  of  oedematous  fluids 
which  contain  uniemic  i)oisons,an  attack  of  unemia  may 
be  preci[)itated.  It  is  safer  first  to  remove  the  oedema  by 
tapping  or  puncture.  Dnistics  are  im[)ortant  aids  in 
preventing  uraemia.  They  must  be  used  with  the  cau- 
tions described  on  pnge  270. 

General  oedema,  if  it   is  not  great,  can  be  made  to 
disappear    by    diuretics,    drastics,   diaphoretics,  or   all 


Acute  Nephritis.  293 

combined.  If  it  is  great,  the  last  group  of  drugs  are  the 
most  efficacious,  but,  as  has  just  been  explained,  must 
be  used  with  caution.  Sometimes  ascites  and  pleural 
and  pericardial  effusions  can  be  removed  by  the  same 
means,  but  usually  less  prom[)tl3^  and  less  perreetl}^  The 
serous  sacs,  often,  must  be  drained.  Rapid  drainage  of 
the  smaller  ones  is  best  accomplished  b^'  an  aspirator, 
and  of  the  larger  by  a  trocar.  If  diuretics,  and  occa- 
sionall}'  drastics,  or,  instead,  a  hot-air  bath  is  given, 
refilling  of  the  sacs  can  be  prevented.  If  general  oedema 
is  great,  and  if  ureemic  symptoms  are  present  or  feared, 
it  is  best  to  withdraw  the  dropsical  interstitial  fluid 
through  deep  ankle  incisions.  These  are  made  prefer- 
ably over  the  inner  malleoli.  They  should  be  deep 
enough  to  incise  all  the  tissues  down  to  the  j^eriosteum, 
and  should  be  at  least  three-fourths  of  an  inch  long. 
After  the  incisions  are  made  the  patient  should  sit  erect, 
or  be  placed  in  a  semi-reclining  posture,  with  the  feet 
lowered  as  much  as  possible,  that  the  fluids  ma}'  gravi- 
tate to  them  and  flow  freeh'  from  the  wounds.  In 
twenty-four  hours  all  the  interstititd  dropsy  can  usually 
be  removed  from  the  bod}',  and,  by  other  means,  it  can 
l)e  prevented  from  re-accumulating. 

During  the  period  of  recovery  the  greatest  care  must 
be  taken  to  prevent  exacerbations  by  a  regulated  diet, 
by  rest,  and  by  careful  clothing,  so  that  the  skin's  tem- 
perature will  be  kept  equable.  During  convalescence  it 
is  often  advisable  to  send  patients  from  our  raw  and 
changeable  winter  and  spring  climate  to  a  warmer  and 
more  equable  one,  such  as  can  be  found  in  Florida, 
Georgia,  and  Southwestern  Texas. 

Iron,  strychnia,  and  other  bitter  tonics  are  now  most 
useful.  The  iron  will  cure  the  annemia,  which  is  inci- 
dental  to    the    disease,   and    it   helps    to    prevent   and 


294  Renal  Inflammations. 

counternct  the  degeneration  of  reniil  epitlieliuni.  Stiych- 
iiia  is  perha[)s  tlie  most  powerful  stiniuhint  of  nutrition 
that  ue  possess.  Quinine  and,  to  a  less  extent,  other 
bitters,  like  gentian,  act  in  the  same  way. 

So  soon  as  the  kidneys  i)erf()rm  their  function  fairly 
diuretics  can  be  gradually  omitted.  Digitalis  can  usually 
be  discontinued  before  the  alkaline  diuretics  are,  as  they 
ma}'  be  longer  needed  to  maintain  the  urine  alkaline,  the 
tubules  free,  and  the  elimination  of  nitrogenous  matter 
abundant. 

The  urine  should  be  examined  daily  during  the  acute 
period  of  the  disease,  and  particularly  with  reference  to 
the  amount  of  nitrogenous  matter  that  is  eliminated. 
During  convalescence  it  need  not  be  examined  so  often, 
but  should  be  occasionally  for  some  weeks,  even  after 
albumen  has  disappeared  from  it.  So  long  as  there  is 
albuminuria  exercise  should  be  forbidden,  altiiough,  in  a 
good  climate  and  favorable  seasons,  carriage-riding  may 
be  permitted  during  convalescence,  and  the  pntient  may 
be  moved  from  room  to  room,  so  thnt  the  mind  may  be 
kept  buoyant  by  variety  and  change. 

Prognosis. — The  prognosis  of  acute  nei)hritis  is  gen- 
eralh'  favorable,  for  almost  all  cnses  recover.  It  is 
usually'  considered  less  severe  in  later  life  than  in  early 
manhood  or  childhood.  The  danger  to  life  is  from 
uraemia  and  various  complications.  If  the  urine  is  very 
scant  the  case  must  be  regarded  as  grave,  because  of  the 
danger  of  unemia.  If  pneumonia  or  em[)yema  develop, 
death  is  almost  certain.  Extensive  dropsy  increases 
the  gravit}'  of  a  case,  es})eci!vlly  if  the  pleural  or  peri- 
cardial sacs  are  involved.  A  small  proi)()rtion  of  cases 
become  chronic.  If  the  acute  nephritis  is  secondary', 
the  character  and  gravity  of  the  primary  disease  must 
modify  or  shape  a  prognosis. 


CHAPTER   XXXII. 

Chronic  Parenchymatous  Nephritis. 

Causes. — Chronic  parenchymatous  nephritis  often 
follows  acute,  but  oftener  it  begins  as  a  chronic  disease. 
Scarlatina  is  a  frequent  cause  of  it.  Ciironic  sup- 
puration may  produce  chronic  nephi'itis  alone  or  com- 
bined with  amyhjid  infiltration.  Malaria  and  S3'philis 
are  two  diseases  out  of  which  it  often  develops.  The 
uric-acid  diathesis,  gout,  and  rheumatism  are  also  causes. 
The  constant  use  of  alcohol,  and  especially  of  the  stronger 
beverages,  predisposes  to  the  disease,  and  sometimes 
undoubtedly  provokes  it.  Man}'  cases  arise  without 
assignable  cause.  Exposure  to  wet  and  cold  and  change- 
able atmospheres  is  regarded  by  some  as  provocative 
of  mnny  of  these  cases.  I  must  agree  with  Ralfe  in 
believing  that  work  upon  damp  and  cold  ground,  or  a 
residence  in  rooms  that  are  damp  and  cold,  is  much 
oftener  a  cause. 

The  disease  occurs  most  frequentl}^  in  males  and 
during  the  first  half  of  adult  life.  It  is  rare  in  childhood 
and  of  occasional  occurrence  in  advanced  life. 

Anatomy. — When  the  disease  attains  its  fidl  maturit}^ 
a  lesion  is  developed  that  differs  greatl}^  from  that  of  its 
early  period.  These  differing  states  may  be  described 
as  its  first  and  second  stages. 

In  the  first  stage  the  kidneys  are  much  enlarged. 
They  may  be  two  or  three  times  larger  than  natui'nl. 
The  capsule  is  smooth,  and  can  be  readily  stripped  fi-om 
the  kidnej^'s  substance.  When  the  organ  is  much  en- 
larged it  will  gape  through  an  incision  in  the  capsule. 
The   surface  of  the  organ  is   usuall}^  mottled  gra}^,  or 

(295) 


296  Renal  Inflammations. 

often  almost  white  and  red.  These  colors  ma}'  exist  in 
varying  proportion.  Many  times  the  red  areas  are  pale 
red.  In  numerons  cases  the  kidney's  surface  is  uni- 
formly white  or  yellow-white.  When  a  section  is  made 
through  the  kidney  the  enlargement  will  be  seen  to  be 
due  to  a  broadening  of  the  cortex.  It  is  often  twice  its 
usual  size.  The  cut  surface  of  the  cortex  will  be  mottled 
or  uniforml}'  yellowish  white,  as  is  the  surHice  of  the 
organ.  The  pyramids  are  red  or,  rarely,  pale.  Usuall}', 
there  is  a  strong  contrast  of  color  between  the  cortex 
and  pyramids.  Tiie  yellow  color  of  the  kidney  is  due 
to  fatty  degeneration.  This  is  the  most  characteristic 
renal  change  in  this  disease.  The  microscope  will  re- 
veal the  degeneration  most  clearl}'.  The  epithelium 
of  the  renal  tubules  is  the  focus  of  the  degeneration. 
Its  cells  are  often  swollen,  very  granular,  and  contain 
numerous  visible  droplets  of  fat.  When  swollen  the}' 
may  nearl}'^  occlude  a  tubule.  The}'  frequently  disinte- 
grate, and  fill  the  tubules  with  a  granular  detritus  tyid 
oil-droplets.  When  the  cells  are  cast  off  they  are  usu- 
all}'  replaced  b}'  new  ones  that  are  thin,  and,  therefore, 
enlarge  the  calibre  of  the  tubules.  These  changes 
are  most  marked  in  the  convoluted  tubules,  but  are  ob- 
servable, also,  in  the  others,  AVithin  the  tubules  h^'aline 
casts  are  abundant,  and  granular  matter,  desquamated 
epithelium,  occasionally  leucocytes,  and  red  blood-cor- 
puscles exicit  in  varying  amounts.  The  glomeruli  are 
usuall}'  not  changed  in  size,  but  sometimes  tho}-  are  a 
little  enlarged.  Many  of  them  are  normal  in  apjiear- 
ance  ;  many  of  the  others  have  thickened  cnpsules.  Tlie 
capsular  epithelium  proliferates  and  en  uses  the  thicken- 
ing. Sometimes  this  thickened  tissue  becomes  partly  or 
wholly  homogeneous  or  hyaline.  Fatty  degeneration  is 
most  common  in  these  cells.     The  epithelium  coyei'ing 


Chronic  Parenchymatous  Nephritis.  297 

the  capillary  tuft  is  also  thickened.  Haemorrhages 
sometimes  take  place  into  the  glomeruli,  and  also  into 
the  intertubular  tissue.  In  the  rare  cases,  which  are 
called  chronic  hsemorrhagic  nephritis,  the>'  are  abundant 
and  almost  constant.  The  tuft  of  capillaries  sometimes 
contracts  or  atrophies,  and  may,  in  part  or  wholly,  be- 
come hyaline.  The  stroma  of  the  kidney  always  con- 
tains a  serous  exudate,  but  in  places,  especially  near  the 
glomeruli  and  about  interlobular  veins,  there  are  cellular 
exudates.  Sometimes,  in  the  cells  of  the  interstitial 
tissue,  droplets  of  fnt  can  be  seen. 

In  the  second  stage  the  kidney  is  not  so  large  or,  in 
the  most  marked  cases,  contracted.  Its  surfjice  is  gran- 
ular or  rough,  at  least  in  spots,  and  sometimes  gen- 
erall}'.  It  is  mottled  or  uniforml}^  yellowish  white. 
The  capsule  is  adherent  where  the  surface  is  contracted. 
The  cut  surface  of  the  cortex  exhibits  an  irregular  out- 
line, and  shows  that  it  is  a  cortical  contraction  that 
causes  the  general  renal  contraction.  Under  the  micro- 
scope the  points  of  greatest  contraction  will  be  seen  to 
be  composed  chiefly  of  connective  tissue.  The  tubules 
are  contracted,  atrophied,  and  often  obliterated.  The 
glomeruli  are  small ;  their  capillary  tufts  are  much  con- 
tracted. The  glomerular  capsule  is  thick.  Both  tuft 
and  capsule  are  often  homogeneous  and  hyaline.  Be- 
tween these  areas  of  contraction  are  others  that  exhibit 
the  lesions  of  the  earlier  stage.  The  contracted  areas 
are  usually  near  the  surfnce  of  the  kidney  and  in  the 
interlobular  districts.  A  desquamation  of  epithelium 
from  the  tubules,  which  then  collapse  and  are  obliterated, 
precedes  the  proliferation  of  connective  tissue  and  dis- 
appearance of  normal  renal  structure.  The  interstitial 
tissues  now  proliferate,  and  the  exuded  leucocytes  help 
to  produce  new  tissue,  in  the  process  of  whose  develop- 

13* 


298  Renal  Infiammations. 

raent  adhesions  form  with  the  renal  capsules.  The 
interstitial  changes  lead  to  compression  of  neighboring 
tubules  and  to  interference  with  the  capillar}'  circula- 
tion. This  in  turn  leads  to  more  destruction  of  epithe- 
lium and  an  extension  of  the  lesion  of  induration.  Such 
changes  occur  onl}^  in  the  most  chronic  cases. 

Besides  these  characteristic  renal  lesions,  oedema  of 
the  subcutaneous  tissue  and  of  the  serous  sacs  is  com- 
mon, and  less  frequently  oedema  of  the  lungs  or  glottis 
occurs.  Cardiac  hypertrophj-  is  common.  It  may  be 
either  unilateral  or  bilateral.  Valvular  lesions  of  the 
heart  occur  in  about  25  per  cent,  of  cases. 

It  is  quite  evident,  from  the  nature  of  these  patho- 
loo^ical  changes,  that  diuresis  must  be  lessened  in  the 
first  stage,  but  in  the  second  it  may  be  increased,  be- 
cause of  the  interference  with  the  circulation,  and  con- 
sequent increased  arterial  pressure  which  the  cirrhosis 
produces.  On  account  of  the  destruction  of  epithelium 
or  interference  with  its  function,  there  is  a  lessening  of 
excretion  of  urinarj'  solids  in  both  stages.  Thus,  the 
same  functional  derangements  that  exist  in  acute  ne- 
phritis are  produced,  but,  because  of  the  insidious  and 
slow  development  of  chronic  nephritis,  its  clinical,  as 
well  as  its  pathological,  picture  differs  greath'  from  that 
of  acute  nephritis. 

Symptoms. — Chronic  nephritis  ma^'  develop  from 
acute,  and  is  especially  apt  to  when  scarlet  fever  is  the 
primary  cause  of  the  nephritis.  But  its  most  charac- 
teristic type  begins  as  a  chronic  affection.  When  it  de- 
velops from  the  acute,  red  corpuscles  graduallv  disap- 
pear from  the  urine,  but  the  albumen  in  it  may  increase. 
In  varying  amounts  there  are,  also,  casts,  cells  nnd  their 
detritus,  and  oil-droplets  either  floating  in  the  urine  or 
imbedded  in  the  casts  and  cells.     (Edema  persists,  or, 


Chronic  Parenchymatous  Nephritis.  299 

at   times,   disappears    partly    or   wholh',   to    re-appear 
occasionalh\ 

When  its  onset  is  insidious  the  disease  may  be  dis- 
covered by  a  chance  urinalysis.  The  patient  may  com- 
phiin  only  of  weakness,  of  anorexia,  of  asthma,  or  some 
symptom  of  chronic  uraemia.  Quite  as  often  attention 
is  attracted  to  the  condition  of  the  kidneys  b}^  the  de- 
velopment of  oedema.  The  latter  is  oftenest  first  no- 
ticed in  puffed  eyelids  in  the  morning,  or  swollen  ankles 
at  night.  When  the  disease  is  chronic  from  its  incep- 
tion, drops}'  may  not  develop  until  it  has  been  estab- 
lished for  weeks  or  months.  At  first,  it  may  flnctuate, 
disappear  for  a  few  days,  to  re-appear,  or  lessen,  and 
again  increase.  When  once  developed,  it  rarely  disap- 
pears entirely  or  for  long.  As  a  rule,  in  spite  of  tem- 
porary abatement  by  treatment,  it  will  increase  and  dis- 
tend the  subcntaneous  tissue  over  the  whole  body.  The 
abdominal  cavity  is  generally  filled,  and  sometimes  the 
pleural  or  pericardial  cavities  are  also.  When  oedema 
is  great  the  scrotum  is  usually'  distended  and  the  skin 
of  the  penis  much  swollen  and  deformed.  The  legs  will 
become  so  large  that  the  tightly-stretched  skin  is  glass- 
like in  smoothness.  Great  stretching  of  the  skin  usually 
causes  malnutrition,  and  eczema  breaks  out  upon  it. 
Occasionally,  gangrene  will  occur,  sloughs  will  form, 
and  leave  deep  and  ver}'  sluggish  ulcers.  Not  unfre- 
quentl}'  from  an  eczematous  surface  upon  the  legs,  and 
oftener  from  deep  cutaneous  ulcers,  the  serum  will  flow 
so  rapidly  as  to  drain  the  tissues  of  their  fluid  and  cause 
a  partial  or  complete  disappearance  of  dropsy.  Eczema 
may  attack  other  parts  of  the  body,  but  the  legs  and 
scrotum  are  its  favorite  sites.  Ascites  is  often  so  great 
that  it  compresses  the  abdominal  viscera  and  prevents 
hearty  eating  even  when  there  is  an  appetite.    It  crowds 


300  Renal  Inflammations. 

the  diaphragm  upward,  often  displaces  the  heart  and 
prevents  a  free  expansion  of  the  hmgs.  Ascitic  pa- 
tients are,  therefore,  short-winded.  Tiie}'  frequent!}' 
avoid  the  reclining  posture,  because  the  fluid  gravitates 
against  the  diaphragm  and  makes  respiration  painfull}- 
short  and  labored.  When  the  second  stage  of  the  dis- 
ease develops,  the  iucreased  diuresis  sometimes  causes 
the  drops}'  to  disappear.  In  rare  cases  of  chronic 
parenchymatous  ne[)hritis,  dropsy  does  not  develop; 
but  it  occurs  more  uniformly  and  more  persistently  in 
it  than  in  an}'  other  form  of  renal  disease.  Its  amount 
varies  inversely  as  the  quantity  of  urine  varies. 

As  in  other  forms  of  nephritis,  the  urine  furnishes 
the  most  pathognomonic  signs  of  the  malady.  In  the 
first  stage  of  this  disease  the  urine  is  diminished  in 
amount.  This  diminution  may  be  moderate,  or  it  may 
be  to  from  150  to  350  cubic  centimetres  (6  to  12  ounces) 
a  day.  It  is  usually  dark  colored  and  turbid.  Its  spe- 
cific gravity  varies  from  1020  to  1040  nnd  is  usually 
greater  than  is  normal.  Its  reaction  is  acid.  Albumen 
is  abundant  in  it.  Commonly,  it  amounts  to  about  1  per 
cent.,  but  may  be  more  than  5  per  cent.  If  the  disease 
develop  insidiously,  the  amount  of  albumen  is  at  first 
small  and  gradually  increases.  There  is  an  abundant 
sediment  in  the  urine.  This  contains  urates;  often  a 
few  red  corpuscles  from  the  blood  ;  granular  and  fatty 
epithelial  cells,  which  are  always  present,  and  are  at 
times  very  abundant ;  casts  and  some  granular  matter, 
intermingled  wnth  which  oil-drops  caii  generally  be  dis- 
covered. The  casts  nt  first  nre  long,  narrow,  hyjiline,  or 
granular;  later,  they  nre  shorter,  broader,  nnd  more 
granulnr  and  fatty.  Sometimes  a  few  granuhir  or  f\itty 
epithelial  cells  will  adhere  to  them.  The  presence  of  oil- 
droplets,  or  fatty  cells  or  casts,  is  particularly  charac- 


Chronic  Parenchymatous  Nephritis.  301 

teristic  of  this  form  of  nephritis.  Red  corpuscles  from 
the  blood  are  often  absent  in  individual  specimens,  but 
may  be  ver}^  abundant  when  so-called  acute  exacerba- 
tions occur.  Then  the  urine  diminishes  still  more  in 
amount,  becomes  red  and  cloudy,  of  high  specific  gravitj', 
and  abundantl}'  albuminous.  It  resembles  verj'  closely 
the  urine  of  acute  nephritis,  but  contains  more  oil  and 
fatt}'  matter. 

The  urinary  solids  are  alwaj's  diminished  in  amount. 
Especially  is  urea  diminished  ;  chlorides  are  less  so,  and 
phosphates  and  sulphates  least.  The  percentage  of  urea 
in  single  saniples  of  urine  is  often  increased,  although 
the  total  eliminated  in  twenty-four  hours  is  much  dimin- 
ished. The  amount  of  urea  voided  daily  will  vary.  It 
may  be  normal  for  some  days,  and  then  ma}^  be  dimin- 
ished. 

In  the  second  stage  of  the  disease,  the  quantity  of 
urine  voided  daily  is  commonlj'  normal,  or  more  than 
normal.  It  is  ligliter  colored  and  clearer  than  in  the 
earlier  stage.  Its  specific- gravity  will  var}^  from  1010 
to  1015.  The  quantity  of  albumen  lessens,  and  the 
dail}'  excretion  of  urea  is  still  more  diminished.  These 
urinary  changes  are  characteristic  of  contracted  kidne}'. 
The  formed  elements  in  the  urine  are  less  abundant  than 
in  the  early  stage,  but  like  them. 

In  the  first  stage  the  pulse  is  usually  small  and 
soft.  It  ma}'  be  quicker  than  normal  if  the  patient  is 
feeble,  excited,  or  hurried.  Tiu'  iieart  is  usually,  at 
first,  not  hypertrophied  or  dilated.  Later,  one  or  both 
changes  will  occur  in  the  left  ventricle,  and  sometimes 
in  both  ventricles.  If  the  kidney  become  hardened 
and  contracted  and  the  blood's  circulation  through  it 
impeded,  an  hypertrophy  of  the  left  ventricle  occurs, 
and  usually  moderate   dilatation.     But  even  when  the 


302  Renal  Injiammations. 

kidney  does  not  contract,  if  the  patient  grow  feeble 
:ind  oedema  is  considerable,  some,  and  at  times  very 
great,  dilatation  of  the  ventricles  takes  phice  withont 
hypertrophy.  Sometimes  hypertro[)hy  of  the  left  ven- 
tricle occurs  in  this  disease  without  assignable  cause, 
unless  there  are  irritants  in  the  blood  that  may  provoke 
it.  Hypertrophy  of  the  right  ventricle  is  i)robably  due  to 
failure  on  the  part  of  the  left  to  maintain  an  equilibrium 
between  the  arterial  and  venous  circulation.  This 
causes  passive  engorgement  of  the  lungs,  which  must  be 
overcome  by  the  right  ventricle.  When  the  heart  is 
dilated  and  feeble  clots  are  liable  to  form  in  it,  and  may 
cause  the  various  phenomena  of  cardiac  thrombosis. 
The  state  of  the  blood  in  this  disease  [)redisposes  to 
thrombosis.  It  contains  a  larger  proportion  of  water 
and  fibrin-makers  than  is  normal ;  a  diminished  number 
of  corpuscles  and  albumen  ;  a  somewhat  increas"ed 
amount  of  fats  and  salts.  The  quantity  of  urea  in  it 
varies  inversely  with  the  power  of  the  kidneys  and  skin 
to  eliminate  it.  The  anaemic  condition  of  the  blood 
sometimes  produces  cardiac  murmurs.  Accidental  mur- 
murs rarely  occur  as  the  result  of  cardiac  dilatation 
independenth'  of  the  anaemia,  and  still  more  rarely  the}' 
are  due  to  interference  with  the  action  of  the  valves  by 
thrombi  formed  on  them  or  their  muscular  ])apill8B. 

In  the  second  stage  of  the  disease  the  pulse  becomes 
liard.  The  physical  signs  of  cardiac  hypertrophy  are 
demonstrable.  If  an  enlargement  of  the  heart  cannot 
be  shown  to  exist,  an  unusually  forceful  apex-beat,  and 
often  one  displaced  downward  and  to  the  left,  and  an 
accentuation  of  the  second  sound  over  the  aorta  are 
proof  of  it.  Haemorrhages  may  occur  from  the  nose 
and  other  mucous  membranes.  The  state  of  the  blood 
ap^  a  cardiac  hypertroi)hy  will  dispose  to  them.     Albu- 


Chronic  Parenchymatous  Nep/i/ritis.  303 

minuric  retinitis  (see  pnge  321),  while  possible,  is  not 
common,  und  is  especiall}-  rare  in  the  first  stage  of  the 
disease.  Tiie  tempenitiire  is  normal,  unless  some  com- 
plicating inflammation  causes  it  to  rise. 

The  skin  is  usually  dry  and  rough.  Though  it  is 
pale,  it  has  not  the  clear,  white  color  that  is  often 
seen  in  acute  nephritis.  It  is  yellowish  or  parch- 
ment-like. This  is  especially  true  of  the  most  chronic 
cases. 

A  gradual  but  marked  loss  of  strength  and  flesh 
takes  place  from  the  first.  During  periods  of  remission 
in  the  course  of  the  disease  some  gain  may  occur,  but 
such  gains  are  only  temporar}'.  Emaciation  is  often 
masked  by  drops3^  It  is  very  evident  when  the  latter 
is  removed.  Loss  of  strength  will,  in  time,  confine  a 
patient  to  the  house  and  to  the  bed.  Respiration  will 
not  be  interfered  with,  except  by  cedemas,  such  as 
excessive  ascites ;  pleural,  pulmonary,  or  lar3ngeal 
dropsy.     Chronic  unemia  ma}'  cause  asthma. 

Lack  of  appetite  is  an  early  and  usually  persistent 
s^'mptom.  Nausea  and  vomiting  are  sometimes  due  to 
indigestion,  but  often  to  uraemia.  When  oedema  is 
great,  a  serous  fluid  is  sometimes  vomited,  which  is 
dropsical  in  origin.  In  such  cases  there  is  often  a 
serous  diarrhoea,  which  is  also  due  to  intestinal  oedema. 
Rarely,  intestinal  ulceration  complicates  chronic  nephri- 
tis. In  many  cases,  although  there  is  little  appetite  for 
food,  there  is  no  demonstrable  failure  to  digest  what  is 
taken.  If  vomiting  and  nausea  occur, unassociated  with 
evidences  of  indigestion,  the}'  are  usually  due  to  uraemia. 
Recently,  Biernacki  has  studied  gastric  digestion  Avith 
care,  in  cases  of  Bright's  disease.  He  finds  free  hydro- 
chloric acid  in  tlie  stomach  in  diminished  amount,  and 
sometimes  wholly  absent ;  pepsin  apparently  diminished, 


304  Renal  Inflammations. 

and  lactic  acid  in  only  small  qnantities.  These  changes 
occurred  both  with  and  withont  symptoms  of  indigestion. 

A  lack  of  energy  and  ambition  is  as  evident,  as  a 
lack  of  muscular  strength,  even  in  the  beginnings  of  the 
disease.  Acute  uraemia  occurs  less  frequentlj'  in 
chronic  parenchymatous  nephritis  than  in  other  renal 
inflammations.  Mild  chronic  uraemia  is  not  very  un- 
common. If  severe  uraemia  occur,  it  is  usuall}^  when 
there  are  acute  exacerbations  of  the  nephritis,  or  toward 
the  close  of  life.  In  the  second  stage  uraemia  is  rela- 
tively frequent,  but  it  is  not  so  common  as  in  interstitial 
nephritis.  It  is  probable  that  several  factors  contribute 
to  produce  lunenitj^  to  uraemia.  The  diminished  appe- 
tite and  disinclination  for  albuminous  foods  help  to  pre- 
*vent  the  formation  of  uraemic  poisons.  The  slow  waste 
of  the  tissues  and  disinclination  for  active  exertion  pre- 
vent the  rapid  formation  of  them  from  the  living  tissues. 
Much  urea  and  presumabh'  other  effete  and  toxic 
matter  is  stored  in  the  dropsical  accumulations  which 
are  usualh'  so  abundant. 

The  second  stage  of  the  disease  is  characterized  by 
an  incrensed  flow  of  watery  urine,  by  a  disappearance 
of  drops}',  by  a  pulse  of  high  tension,  cardiac  hyper- 
trophy, and  b}^  relativel}^  frequent  ura?mia. 

In  the  course  of  chronic  parenchymatous  nephritis, 
exacerbations  often  occur  which  closely  resemble 
attacks  of  acute  renal  inflammation.  The}'  occur  oftenest 
in  those  cases  that  w'ere  at  first  acute,  or  in  those  that 
are  sometimes  denominated  chronic  ha^morrhngic  ne- 
phritis. The  latter  jire  characterized  pathologicall}'  by 
a  mottling  of  the  surface  and  interior  of  the  cortex  with 
red  and  vellow  areas,  and  by  numerous  minute  points 
of  Ineinorrhage.  Undoubtedly,  exi)osure  to  cold  and 
dampness  often  precipitates  these  attacks. 


Chronic  Parenchymatous  Nephritis.  305 

The  disease  may  last  for  months  or  even  years.  Re- 
covery is  very  rare.  The  longer  it  lasts,  the  less  are  the 
chances  of  recovery.  Few  cases  exceed  two  years  in 
their  duration,  unless  renal  contraction  occurs.  They 
may  then  be  more  protracted.  A  larger  proportion  do 
not  exceed  one  year.  Death  ma}^  result  from  uraemia 
suddenly,  from  drops}'  which  disables  one  of  the  organs 
essential  to  life,  or  from  complicating  inllnmmations  like 
pleurisy  or  pneumonia. 

Diagnosis. — A  direct  diagnosis  is  usually  possible. 
It  is  based  (1)  upon  the  character  of  the  urine,  (2)  npon 
the  character  of  tlie  anaemia,, (3)  upon  more  or  less  con- 
stant and  usuall}'  considerable  oedema,  and  (4)  upon  the 
chronicity  of  the  disease.  It  must,  sometimes,  be  dif- 
ferentiated from  acute  renal  inflammation,  from  amyloid 
kidne}',  and  the  second  stage  from  interstitial  nephri- 
tis. It  is  chiefly  apt  to  be  confounded  with  acute 
nephritis  when  so-called  acute  exacerbations  occur,  or 
when  acute  cases  tend  to  become  chronic.  Acute  ex- 
acerbations are  distinguished  from  acute  nephritis  by 
the  history  of  prior  oedema,  or  of  other  symptoms  of 
nephritis,  and  by  the  existence  in  the  urine  of  fatty 
cells  and  casts,  and  often  free  oil-dro[)lets.  Usually,  the 
complexion  is  different.  It  is  a  purer  white  in  the  acute 
disease.  If  the  kidney  is  am3'loid  only,  the  urine  may 
be  undiminished  in  amount,  or  even  increased,  and  will 
contain  abundant  albumen.  The  most  significant  symp- 
toms of  lardaceous  kidne}' are,  besides  the  existence  of  a 
cause  for  the  lesion,  the  co-existence  of  enlargement  and 
hardening  of  the  spleen  and  liver.  When,  as  not  unfre- 
quenth'  happens,  chronic  nephritis  and  amj^loid  infiltra- 
tion co-exist,  a  diagnosis  of  both  lesions  ma3M)e  impossible. 
It  is  only  necessary  to  distinguish  chronic  parenchyma- 
tous  nephritis    from  interstitial  when  the  former  has 


306  Renal  Inflammations. 

reached  its  second  stage.  The  urine  may  be  very  simi- 
lar from  both  these  lesions,  though  usually  from  the 
former  it  is  less  abundant,  more  albuminous,  and  of 
higher  specific  gravity.  In  the  cases  of  parench3^matous 
nephritis  tliere  is  a  histor3'  of  former  oedema,  which  is 
rare  in  interstitial  nephritis,  except  in  the  last  stage. 
The  diagnosis  will,  therefore,  depend  chiefly  upon  the 
history  of  the  development  of  the  disease. 

Treatment. — Whenever  it  is  possible,  the  cause  of 
chronic  nephritis  should  be  removed.  This  can  be  done 
by  draining  abscesses,  by  treating  S3-philis  or  malaria, 
by  discontinuing  the  use  of  alcohol,  or  other  renal 
irritants. 

If  the  disease  begin  as  acute  nephritis,  it  must  be 
treated  as  the  latter  should  be  :  To  maintain  the  per- 
meabilit3"  of  the  uriniferous  tubules  the  urine  should  be 
kept  alkaline  ;  to  prevent  renal  congestion  and  cardiac 
h3^pertr()ph3^,  or  to  lessen  oedema,  the  circulation  should 
be  equalized  b3^  laxatives ;  to  lessen  oedema,  and  es- 
pecially to  prevent  uneniia,  hot-air  baths  and  rest  should 
be  relied  upon;  to  maintain  nutrition,  and  to  prompt 
the  kidneys  to  greater  activit3',  a  milk  diet  should  be 
maintained  ;  eggs  and  meat  should  be  forbidden.  Such  a 
course  of  treatment  will  usually-  lead  to  marked  im[)rove- 
ment,  and  often  even  to  recover3\  During  convalescence, 
patients  must  be  carefull3^  guarded  against  relapse. 
Its  possibility  must  be  remembered  even  for  a  year  or 
more,  and  it  should  be  averted  by  proph3hictic  measures 
similar  to  those  that  are  necessar3^  in  the  course  of  the 
disease  to  avoid  acute  exacerbations. 

If  the  disease  is  chronic  from  the  first,  the  indica- 
tions are:  (1)  to  guard  against  acute  exacerbations,  (2) 
to  prevent  or  limit  fatt3^  degeneration,  (3)  to  lessen  the 
excretion  of  albumen  when  it  is  excessive,  (4)  to  pre- 


Chronic  Parenchymatous  Nephritis.  307 

vent  ui'femia,  and  (5)  to  lessen  oedema.  If  the  second 
stage  is  reached,  we  may  attempt  to  lessen  (1)  the  inter- 
stitial hyperphisia  which  characterizes  it,  and  (2)  cardiac 
hypertro[)hy. 

Acute  exacerbations  can  be  best  avoided  by  clothing 
those  who  have  chronic  nephritis  in  woolen  or  other 
underwear  that  will  maintain  an  equable  surface  tem- 
perature for  the  bod3',  or  at  least  pi'event  sudden  sur- 
face changes.  A  residence  in  an  equable  climate  is 
extremely  desirable.  Patients  should  especially  avoid 
damp  and  cold  climates,  and  houses  that  are  damp  or 
upon  soil  imperfectly  drained.  All  substances  that,  by 
elimination  through  the  kidneys,  irritate  them  should 
be  avoided.  A  milk  diet  is,  in  most  cases,  almost  a 
specific,  so  favorably  does  it  iuHuence  the  disease. 

The  most  characteristic  feature  of  the  lesion  is  fatty 
degenertition.  A  milk  diet,  or,  at  least,  one  easily 
digested  and  assimilated,  is  essential  to  i)revent  this,  by 
maintaining  a  healthful  nutrition  of  the  renal  c'ells. 
Thorough  oxygenation  of  the  blood  is  just  as  necessar}^ 
for  the  maintenance  of  i)erfect  tissue-change.  Therefore, 
the  rooms  of  the  sick  should  be  perfectly  ventilated,  and, 
if  respiration  is  interfered  witli,  or  uraemia  evident  or 
threatening,  oxygen  inhalations  ma}'  possibly  help  both 
to  cleanse  the  blood  and  make  metabolism  more  perfect. 
Of  drugs,  the  most  important  is  iron.  It  seems  particu- 
larly to  limit  or  prevent  degeneration.  Its  preparations 
are  so  numerous  that  there  is  a  wide  field  for  choice. 
The  prei)aratious  which  I  oftenest  use  are  the  citrate, 
the  potassio- tartrate,  the  subcarbonate,  the  iodide,  and 
the  tincture  of  the  chloride.  Occasionalh'  a  change 
should  be  made  from  one  to  another  of  these  prepara- 
tions. If  the  anaemia  does  not  promptl}^  disappear,  or 
the  evidences  of  disease  lessen,  courage  should  not  be 


308  Renal  Injiammations. 

lost  so  long  as  the  S3'mptoms  do  not  become  more  grave, 
for  changes  are  slowl}'  wrought,  in  so  chronic  a  trouble, 
and  tlie  remedies  must  be  perseveringly  used.  Iron 
acts  best  when  given  witli  strychnia,  or  quinia,  or  both. 
The}'- undoubtedly  stimulate  cells  to  greater  nutritive 
activit3\  A  capsule  can  be  given,  three  or  four  times 
daily,  that  will  contain  these  tonics  and  iron  in  combi- 
nation, or  a  solution  of  them  may  be  administered. 
They  should  be  given  in  varied  forms,  but  almost  coii- 
stanth',  for  mojiths. 

In  this  variet}^  of  nephritis  the  loss  of  albumen  is 
considerable,  and  ma}'  contribute  materiall}^  to  cause 
weakness.  Various  drugs  are  used  to  lessen  it.  Some 
of  these. I  am  convinced,  accomplish  the  object, but  I  have 
not  seen  sufficient  improvement  produced  in  the  general 
health  of  a  patient,  while  they  are  used  and  the  albumi- 
nuria is  checked,  to  make  me  confident  of  their  utilit\'. 
The  drugs  which  can  be  most  safel}^  and  efficientl}'  em- 
pl(i(3'ed  to  limit  the  excretion  of  albumen  are:  Tannate 
of  sodium,  which  can  be  given  in  doses  of  from  ^  to  H 
grammes  (5  to  20  grains),  in  water;  tannic  or  gallic 
acid,  in  their  usual  doses  ;  or  nitric  acid,  ergot,  caffeine, 
or  fuchsin.  The  last  is  given,  in  doses  of  from  ^  to  2 
decigrammes  fl  to  3  grains),  in  pills. 

I  have  already  described  full}'  the  methods  b}-  which 
uraemia  is  to  be  avoided  and  treated.  I  need  now  onlv 
outline  the  treatment  most  applicable  to  this  form  of 
nephritis.  If  oedema  is  considerable,  a  patient  should 
remain  in  bed,  or  onl}-  be  moved  to  a  lounge  or  another 
bed.  If  there  is  no,  or  ver\'  little,  oedema,  moderate 
exercise  may  be  permitted  ;  but  it  should  never  be  ex- 
hausting or  ver}^  long  continued,  for  much  exercise 
certainly  increases  the  danger  of  uraemia. 

A  prescribed  diet  is  most  important  in  the  treatment 


Chronic  Par^enchymatous  Nephritis.  309 

of  this  affection,  for  by  a  Ciireful  reguhitioii  of  it  the 
danger  of  unieniia  can  be  greatly  lessened.  Milk  is,  for 
chronic  [)arench\  matoiis  nephritis,  more  than  a  food  ;  it 
is  curative.  Jnst  how  it  produces  its  good  elfects  is  not 
known.  It  is  readily'  digested  and  converted  into  very 
assimilable  nutriment.  It  contains  very  little  of  waste 
or  useless  matter.  It  is  also  diuretic.  These  are  quali- 
ties which  adn[)t  it  especially  to  the  disease.  It  contains 
a  small  amount  of  albumen,  but  not  enough  to  be 
dangerous,  unless  the  dtiily  volume  of  urine  is  ver}' 
greatly  reduced.  Milk,  as  an  exclusive  food,  contains 
an  excess  of  fats.  This  is  undou))tedly  one  reason  why 
it  is  so  perfect  a  food,  although  it  contains  so  little 
albumen,  for  it  is  proven  that  less  albumen  is  needed  in 
proportion  as  fats  and  carbohydrates  are  taken  in 
increased  amounts.  A  strictly  milk  diet,  long  continued, 
lias  often  proved  curative.  Disgust  for  milk  is  fre- 
quently caused  by  restricting  patients  too  quickly  to  a 
diet  of  it  onl3'.  Therefore,  the  regimen  should  be 
restricted  somewhat  gradually'.  Meats,  eggs,  fish,  cheese, 
and  leguminous  vegetables  should  be  first  omitted,  and 
slowly  the  farinaceous  foods  can  be  withdrawn.  A  milk 
diet  is  best  tolerated  when  the  beverage  is  taken  in 
moderate  amounts  ever}'  two  or  three  hours.  It  is  also 
important  that  the  stomach  should  not  be  overloaded, 
as  indigestion,  which  is  likely  to  result  from  it,  usualh^ 
produces  substances  that  irritM-te  the  kidneys  in  the 
process  of  their  elimination,  or  help  to  make  the  blood 
toxic.  If  a  patient  can,  he  should  adhere  to  a  milk 
diet.  Often,  however,  patients  grow  wearied  of  it.  They 
can  occasionally  be  allowed  a  little  fruit,  or  a  soup  made 
of  milk,  flavored  with  some  vegetable,  like  asparagus, 
pease,  or  tomatoes.  Occasionall}',  thin  milk-gruels, 
apple-sauce  and  milk,  or  some  other  fruit  and  milk,  can 


310  Renal  luHammations. 

be  similar!}-  employed  to  vniy  the  diet.  Upon  a  strict!}' 
millc  diet,  a  patient  slioiiU!  ptutalie  of  it  at  about  seven 
and  ten  in  the  morning:  one.  four,  seven,  and  ten  in  the 
afternoon  and  evening.  If  it  is  varied  Ijy  some  of  the 
articles  just  mentioned,  they  may  l)e  substituted  at  ten 
and  four,  or  at  seven  in  the  morning  and  seven  in  the 
evening,  wliile  milk  only  should  be  tid^en  at  other  times. 
But  it  is  best  to  adhere  as  long  as  possibie,  and  in  as 
many  cases  as  possible,  to  a  purel}^  milk  diet.  Often,  if 
the  regimen  is  varied  for  a  few  days,  as  1  Inive  suggested, 
a  milk  diet  can  l)e  ngain  adopted  hy  the  patient  without 
distaste.  When  millv  is  altogether  distjisteful,  and  cannot 
be  taken  in  quantities  sufficient  to  mnintnin  nutrition,  ;i 
farinaceous  and  fruit  diet  must  be  adopted,  but  all 
a!l)uminous  food  should  be  excluded  from  it.  As  pease 
and  Ijeans  contain  consideraljle  amounts  of  nitrogenous 
matter,  the}'  should  not  l)e  used.  If  milk  is  not  taken 
freely,  water  should  be.  It  helps  to  produce  freer  diu- 
resis. It  dilutes  toxic  matter  that  may  be  in  the  blood. 
Distilled  water  or  spring  water  that  is  as  free  of  mineral 
matter  as  possible  is  the  best,  as  it  is  able  to  dissolve 
more  waste  products,  especially  those  imperfectly  pre- 
pared for  solution,  and  therefore  most  apt  to  accu- 
mulate in  the  system.  The  use  of  large  amounts  of 
water  at  springs,  and  the  good  results  which  accrue, 
have  made  many  famous  for  the  treatment  of  renal  dis- 
eases. At  least,  a  glassful  of  water  should  be  taken  at 
each  meal-time,  and  one  between  meals  and  at  bed-time. 
If  patients  cannot  be  kept  on  a  milk  diet,  but  must  be 
allowed  one  that  is  more  varied,  still  greater  care  must 
be  exercised  that  the  stomach  be  not  overci'owded,  or 
indigestion  produced.  Only  so  much  as  can  be  well 
digested  and  assimilated  should  be  taken,  and  it  should 
be  washed  into  the  blood   with  frequent  drafts  of  water. 


Chronic  Parenchymatous  Nej)hriiis.  311 

Diuretics  may  be  relied  upon  to  prevent  iiri^^mia  if  the 
daily  quantity  of  urine  voided  and  of  nitrogenous 
matter  eliminated  is  lessened  a  little  only.  In  more 
urgent  cases  they  may  be  aided  by  occasional  purges  or 
b}^  sweatings.  Diaphoresis,  it  must  be  remembered, 
should  be  provoked  with  care,  or  not  at  all,  if  oedema  is 
great. 

To  relieve  dropsy  reliance  must  again  be  placed  upon 
diuretics,  cathartics,  and  diaphoretics.  If  pleural,  peri- 
cardial, or  peritoneal  drops^^  endanger  life  b}'  compress- 
ing the  lungs  or  the  heart,  it  should  be  relieved  b}'  aspi- 
ration, or  drainage  through  a  trocar.  If  subcutaneous 
oedema  is  great,  and  it  does  not  seem  safe  to  remove  it 
b}'  diaphoresis,  incisions  at  the  ankle  ma}-  be  made,  and 
the  whole  may  be  withdrawn.  When  oedema  is  great 
the  amount  of  urine  voided  daily  is  xery  small,  but  often 
when  the  oedematous  fluid  is  rapidly  withdrawn  through 
incisions  it  will  increase  almost  to  a  normal  quantity. 
Tlie  kidneys  renew  their  activit}^,  and  b}'  careful  treat- 
ment free  diuresis  can  often  be  mainttiined  for  a  long- 
time. Perfect  drainage  of  the  subcutaneous  tissues  is 
usually  accomplished  b}^  ankle  incisions  in  twenty-four 
to  fort3-eight  hours.  The  incisions  generally-  heal  in 
three  or  four  days  after  the  drainage  ceases.  The  pro- 
cedure may  be  repeated  several  times  without  ill  effects. 
The  drainage  of  the  tissues  is  less  likel}^  to  be  complete 
if  the  anasarca  has  been  of  long  standing,  or  if  the 
dropsy  has  often  re-appeared.  The  connective  tissues 
in  which  the  fluid  accumulates  gradually  proliferate, 
and  the  intercommunication  of  lacunar  spaces  and 
lymphatic  channels  becomes  less  perfect. 

If  the  second  stage  of  the  disease  is  developing, 
mercurials  and  the  iodides  may  be  used  to  check  the 
connective-tissue  proliferations.     I  doubt   the    efficacy 


312  Benal  Inflammations. 

of  these  drugs  in  cases  that  have  not  a  syphilitic  origin, 
and  even  in  the  latter  the}^  are  not  alwaj-s  success- 
ful. They  are  both  diuretic,  and  may  aid  patients  b}^ 
virtue  of  that  property..  The  iodides  lower  arterial 
pressure  b}'  dilating  the  arterioles,  and  thus  ma}^  delay 
cardiac  hypertrophy',  dilatation,  and  final  exhaustion. 
The  nitrites  i)roduce  prompter  and  greater  arterial-  re- 
laxation, and,  therefore,  are  often  resorted  to  in  this 
stage  of  the  disease  to  relieve  the  heart  of  overwork. 
(See  pages  218,  228.)  When  the  kidne}'  contracts  there 
is  greater  danger  of  ur?emia  than  in  the  earlier  stage.  It 
must  be  averted  b}-  the  same  means  as  in  other  cases. 
The  danger  most  peculiar  to  this  stage  of  the  disease  is 
cardiac  exhaustion  from  overwork,  and  this  must  be 
prevented,  if  possible. 

Complications,  such  as  pleurisj- ,  pneumonia,  and  en- 
docarditis, must  be  treated  as  the}^  would  be  under  other 
circumstances.  While  many  cases  of  chronic  parenchy- 
matous nephritis  are  incurable,  life  can  often  be  pro- 
longed for  even  manj^  3'ears  b}'  careful  treatment,  which 
will  prevent  fatal  complications. 


CHAPTER  XXXIII. 

I  NTERSTITIAL    NEPHRITIS. 

Causes. — Interstitial  nephritis,  although  it  may  occur 
in  infancy  or  childhood,  is  extremely  rare,  except  in  the 
last  third  of  life.  Deaths  from  it  are  most  frequent 
between  the  fortieth  and  sixtieth  3'ears,  and  especially 
between  the  fiftieth  and  sixtieth  years.  It  is,  however, 
so  eminently  a  chronic  affection  that  its  beginning  must 
be  dated  back  from  five  to  ten  years,  or  longer.  One 
form  of  contracted  kidney  is  associated  with  general 
arterio-sclerosis,  and  is  one  of  the  lesions  common  to 
old  age. 

Renal  cirrhosis  is  three  or  four  times  commoner  in 
men  than  in  women.  It  undoubtedly  occurs  oftener 
among  high  livers  than  among  those  whose  diet  is  sim- 
ple. The  harm  is  probably  done  by  the  extractives  and 
spices  which  are  so  abundant  in  game,  in  richl3'-dressed 
meats  and  soups,  such  as  constitute  a  large  part  of  the 
regimen  of  good  livers.  These  substances,  not  easily 
metamorphosed  in  the  blood  or  tissues,  are  irritants  to 
the  kidneys,  b}^  which  they  must  be  eliminated.  More- 
over, those  who  habitually  live  upon  such  foods  are 
usually  dyspeptics,  and,  therefore,  are  only  able  to  pre- 
pare them  imperfectly  for  assimilation.  In  most  in- 
stances, such  eaters  do  not  drink  freely  of  water,  which, 
if  taken  copioush',  might  wash  these  substances  rapidly 
from  the  system,  and  not  leave  them  long  enough  in  it  to 
cause  prolonged  irritation.  The  beverages  oftenest  used 
by  them  are  the  alcoholics,  which  are  undoubted  renal 
irritants,  and  most  certainl}^  dispose  to  fatty  degenera- 
tion of  the  epithelium.  Writers  upon  this  subject 
almost  unanimous!}'  declare  that  the  excessive  use  of 

14  o  (313^ 


314  Bejial  Inflammations. 

alcoholics  is  the  commonest  cause  of  cirrhotic  kidney. 
Renal  cirrhosis  usually  occurs  in  those  who  use  these 
beverages  steadil}',  but  moderateh'.  The  excessive  use 
of  alcoholic  drinks  leads  often  to  acute  or  oftenest  to 
chronic  parenchymatous  nephritis.  The  pathological 
statistics  collated  by  Formad  prove  this.  My  own 
clinical  observations  confirm  it. 

Gout  and  the  uric-acid  diathesis  are  often  primarj* 
to  renal  cirrhosis.  The  slow  elimination  by  the  kidneys 
of  irritating  nitrogenous  substances  imperfectly  pre- 
pared for  conversion  into  urea  and  eliminable  matter  is 
the  probable  cause  of  the  nephritis. 

Chronic  plumbism  occasionally  produces  renal  cir- 
rhosis. Scarlet  fever  and  malaria  are  rarel}^  primar}'  to 
this  form  of  nephritis.  It  is  sometimes  said  that  pro- 
longed mental  depression  disposes  to  this  renal  lesion. 
It  is  true  that  the  mental  and  renal  trouble  often  co-exist. 
But  it  is  not  demonstrated  that  there  is  a  relation  of 
cause  and  effect  between  them.  Depressed  mental 
states  are  common  to  dyspeptics,  and  also  to  those 
havino-  uric-acid  diathesis.  It  is  more  probable  that 
the  mental  and  renal  state  have  a  common  cause  than 
that  one  is  the  cause  of  the  other. 

In  manj',  though  not  in  a  large  number  of  cases. 
heredity  is  seemingl}'  an  etiological  factor.  Renal  cir- 
rhosis is  commonest  in  temperate  climates.  It  rarel}' 
grows  out  of  acute  nephritis.  If  the  latter  almost  sub- 
side, but  persist  as  a  small  islet  of  chronic  inflamma- 
tion, interstitial  nephritis  may  be  the  result.  It  also 
grows  out  of  chronic  pyelitis,  and  through  it,  indirectly, 
out  of  chronic  cystitis  and  urethritis. 

Anatomy. — Tiie  renal  cirrhosis  which  results  from 
arterio-sclerosis  is  a  lesion  quite  distinct  from  that 
which   results   from   gout^  plumbism,   high   living,  and 


Intei'stitial  Nephritis.  315 

other  cuiises.  When  a  renal  arteriole  is  sclerosed  and 
finally  becomes  nearlj-  or  quite  impermeable,  the  glonier- 
iile  or  group  of  glomeruli  to  which  it  furnishes  afferent 
vessels  contracts.  At  first  the  capillary  loops  become 
shrunken,  hyaline,  and  im[)ermeable.  The  glomerular 
epithelium  is  shed,  and  partl}^  or  wholl>^  disappears. 
The  capsule  contracts  around  the  small  homogeneous 
mass  which  represents  the  former  capillary  tuft.  The 
capsule  sometimes  is  thickened,  but  often  remains 
unchanged.  Such  glomeruli  are  frequently  one-fourth 
to  one-sixth  their  normal  size,  and  are  functionall}-  use- 
less. When  a  glomerulus  ceases  to  pour  fluid  down  its 
uriniferous  tubule  the  latter  also  contracts.  It  at  first 
collapses,  its  epithelial  cells  then  diminish  in  size.  They 
often  fill  the  contracted  tubule.  Sometimes  a  tubule 
will  be  converted  into  a  cyst  b3^  an  obstructing  plug  of 
colloidal  matter.  There  ma^'  be  no  interstitial  change, 
but  usually  small,  abnormal  islets  of  connective  tissue 
are  discernible  about  the  sclerosed  arteries.  These 
minute  changes  cause  an  irregular  contraction  of  the 
renal  cortex  and  make  the  surface  rouoh  or  s^ranular. 
The  kidney  does  not  become  as  tongh  and  hard  as  in 
cases  of  interstitial  h3'perplasia. 

When  there  is  true  interstitial  nephritis,  the  kidneys 
are  imbedded  in  large  amounts  of  fat.  They  are  con- 
tracted, but  not  equally.  The  surface  is  rough  and 
granular,  reddish  brown,  or  rarely  grayish  brown. 
Cysts,  from  the  size  of  a  pin-head  to  a  bean,  are  common, 
both  on  the  surface  and  in  the  renal  substance.  They 
are  distended  with  a  clear  fluid.  The  kidney  is  firm  and 
leather}'  in  consistence.  The  capsule  is  thick  and 
firmly  adherent  to  the  renal  substance  at  the  points  of 
depression  on  its  surface.  A  section  of  the  organ 
exhibits  the  same  color  as  its  surface.     The  granulations 


316  Renal  Inflammations. 

on  the  surface  and  the  tissue  beneath  them  are  dark 
colored.  The  depressed  areas  may  be  grayish.  The 
cortex  has  a  very  irregular  width,  and  is  often  in  places 
very  narrow.  It  may  be  to  the  pyramids  as  one  to  five 
or  as  one  to  six.  The  p3'ramids  are  usually  deepl}^  con- 
gested. The  pelvis  is  often  dilated,  and  sometimes 
inflamed.  In  the  gouty  kidne}^  gray,  hard  streaks  can 
be  seen  and  felt.  These  consist  of  deposits  of  urates  in 
the  interstitial  tissue,  the  epithelium,  or  within  the 
tubules. 

Under  the  microscope  the  thickening  of  the  capsule 
is  seen  to  be  due  to  a  connective-tissue  hyperplasia, 
which  is  greatest  at  the  points  of  dei)ression  on  the  kid- 
ney's surface.  At  these  points  the  cirrhotic  renal  tissue 
and  new  capsular  tissue  are  confluent,  and,  therefore, 
united.  The  areas  of  cirrhosis  are  irregularly  disposed 
in  the  cortical  substance  and,  usually  united  to  a  greater 
or  less  extent,  encircle  more  normnl  territories.  In  the 
centre  of  the  cirrhotic  tissue  renal  structures  cannot  be 
seen.  Fibrous  tissue  only  composes  it.  Toward  the 
periphery  of  these  areas  their  mode  of  extension  can  be 
studied.  The  glomeruli  are  seen  to  be  greatl}'  con- 
tracted or  in  process  of  contraction.  They  may  be  not 
more  than  one-eighth  of  their  normal  dimensions. 
Their  capsules  are  usually  enormously  thickened  by 
concentric  layers  of  fibrous  tissue.  The  capillnries  may 
have  atrophied  and  disappeared,  or  may  be  represented 
])y  a  small  homogeneous,  granular,  or  hyaline  mass. 
No  glomerular  epithelium  can  be  seen.  Occasional!}',  a 
greatl}'  dilated  and  cystic  glomerulus  may  be  observed. 
The  tubules  are  seen  to  be  contracted,  the  epithelium 
lining  them  to  be  atrophying,  or  sometimes  wholl}'  dis- 
integrated. In  the  latter  cise  the  tubule  is  outlined 
only  bv  its  basement  membrane.      The  tubules  then  be- 


Interstitial  Nephritis,  317 

come  obliterated.  As  they  contract  and  disnppear  the 
tissue  between  them  increases  in  amount.  It  is  fibrous 
and  abundant.  Here  and  there  a  ^qw  round  cells  and 
embryonic  connective  tissue  cells  can  be  seen.  The 
tubules  that  are  least  affected  are  often  unusuall}'  tor- 
tuous. The}'  look  nearly  normal  in  places,  and  else- 
where exhibit  the  changes  which  are  seen  in  chronic 
parenchymatous  nephritis.  Such  changes  develop  very 
gradually.  The  atroph}-  of  the  tubules  is  partly  due  to 
disturbance  of  nutrition,  caused  hy  the  interstitial 
changes,  and  partly  by  the  destruction  of  glomeruli. 
When  tubules  become  obstructed  in  part  of  their  course 
onl}^,  they  may  expand  and  form  cj^sts.  Many  arteri- 
oles, especialh'  in  the  cirihotic  areas,  are  made  useless 
by  endarteritis  obliterans.  Usually,  the  entire  arterial 
wall  is  thickened,  but  its  intima  is  especially  so,  and  the 
calibre  of  the  arteriole  is,  therefore,  almost  or  quite 
obliterated.  In  other  cases,  the  tunica  adventitia  and 
muscular  coat  are  thickened  bj^  the  formation  in  them 
of  masses  of  a  waxy  appearance.  These  changes  also 
produce  more  or  less  vascular  stenosis.  Hsemorrhages 
into  the  kidney  are  not  common.  It  is  still  a  question 
whether  the  interstitial  hyperplasia  or  the  tubular  atro- 
phy' is  the  primary  lesion ;  whether  the  interstitial 
changes  cause  the  tubules  to  contract  and  disappear,  or 
whether,  because  of  the  disappearnnce  of  the  latter,  the 
former  undergoes  a  compensatory  hypertrophy. 

Endarteritis  obliterans  and  arterial  sclerosis  also 
often  occur  in  other  organs.  Tlie  left  ventricle  of  the 
heart  is  hypertrophied  and  generally  dilated.  Some- 
times both  ventricles  are.  Occasionally,  points  of  fatty 
degeneration,  or  indurative  degeneration,  can  be  seen  in 
the  heart-muscle.  In  some  cases,  the  endocardium  is 
thickened  in  spots,  or  there  ma}'  be  evidence  of  endar- 


318  Renal  Inflammations. 

teritis.  There  may  also  be  thickening  or  evidence  of 
inflammation  of  the  pericardium,  pleura,  or  peritoneum. 
The  dura  mater  and  arachnoid  may  also  be  thickened. 
Cerebral  haemorrhages  are  common  complications  of 
the  disease.  PulmonarN'  consumption  occurs  less  fre- 
quently, but  often.  Gastric  and  intestinal  catarrh  are 
usual  concomitants  of  the  renal  trouble. 

Symptoms. — Clinically,  three  stages  of  the  disease 
are  recognizable ;  the  first  maj'  be  described  as  the  state 
in  which  there  is  high  arterial  tension  ^Yithout  recogniza- 
ble cardiac  liypertroph}' ;  the  second,  one  in  which  there 
is  cardiac  h3'pertrophy ;  and  third,  one  in  which  there  is 
cardiac  failure.  Death  ma}'  occur,  in  either  of  these 
states,  from  intercurrent  disease,  uraemia,  or  cerebral 
haemorrhage.  Life  is  often  prolonged  for  many  years 
after  the  disease  is  established.  The  malady  may  last 
for  twenty  or  more  years,  and  commonly  does  for  from 
five  to  ten. 

It  is  extremel}^  important  that  this  disease  should  be 
recognized  earl}-,  as  the  danger  to  life  is  much  greater 
after  the  heart  has  lijqDertrophied  ;  and  b}'  careful  treat- 
ment in  its  earl}'  stage  the  advance  to  the  later  ones  can 
be  delayed.  Unfortunately,  the  first  stage  is  not  always 
readily  recognizable. 

The  onset  of  renal  cirrhosis  is  alwnys  insidious.  The 
<iarly  symptoms  do  not  direct  attention  to  the  kidneys. 
In  the  first  stage  most  of  the  syni})toms  are  variable. 
They  will  exist  in  one  case  :ind  not  in  juiother,  or  at  dif- 
ferent times  in  the  same  case.  One  of  the  most  constant 
of  these  variable  symptoms  is  indigestion.  It  is  usually 
very  persistent  when  it  exists.  It  is  characterized  by 
flatulence,  and  rarely  by  pain  and  nausea.  Another  of 
these  early  symptoms  is  headache.  It  may  affect  any 
part  of  the  head,  but  oftenest   it   is  occipital  and   felt 


Interstitial  Nephritis.  319 

chiefl}'  or  onl}^  in  the  morning.  In  many  cases  there  is 
heniicrania.  These  are  undoubtedly  often  S3'mptoms 
of  mild  uraemia.  Yertigo  is  a  common  s3'niptom.  It  is 
usuall}'  momentar}^  but  is  especially  liable  to  recur. 
The  character  of  the  pulse  is  quite  constant.  It  is  fairly 
full  and  regular,  but  unusuall}^  tense.  It  feels  cord-like 
under  the  finger,  and  is  not  readily  compressible.  In 
the  sphygmogram  the  dicrotic  notch  is  elevated  from 
the  respiratory  line,  and  the  line  descending  from  the 
apex  of  the  wave  to  the  dicrotic  notch  is  noticeably 
bowed  upward.  The  urine  is  still  more  characteristic. 
Usuall}',  it  is  made  once  or  twice  during  the  night,  and 
in  quantities  abnormally  large.  This  ma}'  be  the  first 
S3'mptom  that  attracts  the  ph3sician's  attention  to  the 
condition  of  the  kidneys.  It  does  not  alarm  the  patient, 
for  frequent  nocturnal  micturition  develops  so  slowl}* 
that  he  regards  it  as  a  habit,  and  not  as  a  pathological 
condition.  More  urine  is  made  in  twentj^-four  hours 
than  normal,  but  it  is  especially  increased  at  night.  It 
is  usuall}'  limpid  and  clear,  acid  in  reaction,  and  from 
1014  to  1020  in  specific  gravit3\  It  may  be  faintl}- 
albuminous  at  all  times,  or  only  after  a  heart3'  meal  or 
violent  exercise,  and  not  in  the  earl3Mnorning.  But  fre- 
quently it  is  altogether  absent.  On  standing  a  precipi- 
tate ma3"  form,  which  is  usuall3'  composed  of  crystals  of 
calcium  oxalate  and  uric  acid,  with  sometimes  a  few  h3^a- 
line  casts.  The  quantity^  of  urea  voided  in  twent3-four 
hours  is  often  less  than  normal. 

With  these  symptoms  we  get  the  histor3'  of  high 
living,  or  of  some  of  the  usual  causes  of  the  disease. 
If  there  is  persistent  high  arterial  tension  and  none  of 
the  other  common  causes  of  its  existence,  renal  cirrhosis 
should  be  sought  for.  If  high  arterial  tension  co-exist, 
with  the  voiding  of  an  unusuall3^  large  amount  of  urine 


320  Benal  Lijlammations. 

of  low  specific  gravit}-,  which  contains  a  diminished 
proportion  of  urea,  the  existence  of  beginning  renal 
cirrhosis  ma}'  be  looked  upon  as  probable.  If  albumen 
is  present  in  small  amounts,  constantly  or  occasional!}-, 
and  if  hyaline  casts  are  found  in  the  urine,  the  diagnosis 
ma}'  be  made  positiveh*. 

In  the  second  stage  the  symptoms  of  the  first  are 
ascaravated  or  intensified.  Headache  and  vertigo  are 
more  common  than  in  the  first.  If  there  is  indigestion, 
it  is  more  severe.  Not  only  is  there  flatulence,  but  often 
nausea  and  vomiting.  The  gastritis  is  usually  persist- 
ent if  it  exist,  but  varies  greatly  in  intensit}'  from  time 
to  time.  The  pulse  is  even  more  tense  than  in  the  ear- 
lier stage.  The  heart  causes  a  strong  apex-beat  which 
can  be  seen  and  felt,  but  is  somewhat  lower  and  farther 
to  the  left  than  is  normal.  The  cardiac  sounds  are  nor- 
mal. At  the  apex  the  first  sound  is  strong.  Over  the 
aorta  the  second  is  accentuated.  B3-  percussion  the 
area  of  dullness  is  demonstrably  increased  to  the  left. 
Occasionalh',  haemorrhages  from  the  nose,  or  into  tlie 
retina,  or  within  the  brain,  will  occur.  The  uriiiQ  is  even 
more  abundant,  and  more  uniformly  abundant,  and 
made  oftener  at  night  than  in  the  earlier  stnge.  It  is 
more  constantly  limpid  and  clear.  Its  si)ecific  gravity 
is  lower, — from  1004  to  1014.  It  is,  witli  rare  excep- 
tions, slightly  albuminous.  However,  cases  are  observed 
in  which  albumen  is  never  discoverable.  Usuall}-,  it  is, 
occasionalh',  if  it  is  not  constantly,  present.  It  will  be 
found  most  certainly'  in  urine  that  is  made  in  the  even- 
ins;,  after  a  dav's  work,  and  after  a  meal.  The  dailv 
elimination  of  urea  is  oftener  less  than  in  the  first  stage. 
As  in  the  latter,  the  nrine  may  contain  no  sediment,  or, 
if  any,  a  very  small  one.  A  few  casts  can  occasional! v 
!)e  found  in  it.     Tiie}'  are  hyaiine  or  gr.Mnuljn-,  and  mn.y 


Interstitial  Nephritis.  321 

sometimes  contain  a  few  oil-droplets.  Uric  acid  com- 
poses a  part  of  the  scant  sediment.  Cells  are  rarely 
found  in  it. 

Respiration  is  usually  normal.  It  is  rarelj'  dyspnoeic 
from  asthma  which  is  caused  b}^  uraemia,  or  from  pul- 
monary oedema.  The  bronchi  and  lungs  are  especial!}^ 
liable  to  various  inflammations.  In  the  first  stage  there 
may  be  no  oliservable  loss  of  strength,  but  in  this  endur- 
ance and,  usually,  streugth  are  somewhat  lessened.  The 
skin  is  dr}^,  rough,  and  parchment-like  or  gra}^,  but  not 
white  or  clearly  antemic,  as  in  acute  nephritis. 

Nervous  sjniptoms,  usually  of  uraemic  origin,  are 
common.  The  dangerous  ones  are  convulsions  and  coma. 
The  less  dangerous  ones  are  disturbances  of  hearing, 
such  as  roaring,  singing,  or  temporary  deafness  and 
insomnia,  mental  depression,  various  shifting  neuralgias, 
and  numbness.  Uraemia  is  especially  frequent  in  this 
stage  of  the  disease.  The  eyesight  is  often  impaired. 
It  may  be  extensively  affected  bj'  uraemic  amaurosis,  or 
what  is  called  albuminuric  retinitis.  The  first  affection  is 
usually  temporary,  although  blindness  may  be  complete. 
The  blindness  is  generally  sudden  in  onset.  The  pupils 
continue  to  react  to  light,  and  no  changes  are  discoverable 
in  the  retina  that  are  necessarily  associated  with  the 
blindness.  "  Albuminuric  retinitis  "  may  be  due  (1)  to 
oedema  of  the  retina;  (2)  to  degeneration  in  patches, 
which  appear  white,  and  are  fatt}'  or  sclerotic  ;  (3)  to 
haemorrhages;  (4)  to  inflammation  of  the  ocular  end  of 
the  optic  nerve ;  and  (5)  to  atroph}^  of  the  retina  and 
nerve,  produced  b}^  some  of  these  lesions.  Often  more 
than  one  of  these  lesions  co-exist.  They  can  onl}^  be 
diagnosed  by  an  ophthalmoscopic  examination.  The 
subjective  symptoms  vary.  Blindness  may  be  gradually 
or  suddenly  developed  as  a  result  of  them,  or  eyesight 

14* 


322  Renal  Inflammations. 

ma}'  be  imperfect.  All  objects  may  be  blurred,  or  only 
near  ones  or  distant  ones.  Objects  may  appear  distorted. 
Bright  or  dark  spots  ma}^  come  before  the  eyes.  Many 
of  the  symptoms  are  mitigated  b}^  time,  especially  those 
that  arise  suddenl}' ;  but  the}^  rarely  disappear  entirel}'. 
In  the  third  stage  the  prominent  symptoms  are  those 
of  cardiac  exhaustion  and  failure.  The  hypertrophied 
heart  is  dilated,  and  is  usuall}'  degenerated.  The  pulse 
grows  soft,  small,  and  quick.  It  often  becomes  irregu- 
lar. The  area  of  cardiac  dullness  is  increased.  The 
apex-beat  is  displaced  to  the  left.  It  ma}-  be  visible 
and  somewhat  forceful  because  of  hypertroph}'  of  the 
heart-muscle,  although  the  latter  is  too  weak  to  do  its 
work.  In  other  cases  it  can  be  faintly  seen  or  felt.  The 
cardiac  sounds  are  not  so  strong  as  in  the  earlier  stage, 
and  especially  does  the  first  sound  at  the  apex  grow 
short  and  valve-like.  But  more  significant  than  these 
cardiac  chanoes  are  the  diminishinor  excretion  of  urine 
and  the  developing  oedema.  The  urine  maj^  be  much  re- 
duced even  below  the  normal  amount.  The  total  dailj' 
excretion  of  urea  remains  diminished.  The  specific 
gravit}'  may  increase,  but  almost  uniforml}'  remains 
below  the  normal.  Albumen  is  usually  a  little  more 
abundant.  Casts  oftener  contain  fat  or  oil.  (Edema 
begins  first  about  the  legs,  but  sooil  increases  and  ma}'^ 
be  considerable.  Ascites  is  often  present.  The  liver 
frequently  is  congested  and  some  connective-tissue 
hyperplasia  may  develop  and  produce  a  subicteric  stain- 
ing of  the  skin.  Diarrhoea  is  a  common  complication, 
and  one  that  often  proves  intractable.  It  may  be  due  to 
enteritis,  but  is  oftener  due  to  oedema.  The  discharges 
are  usually  copious  and  are  sometimes  streaked  or  mixed 
with  blood.  In  this  stage  patients  are  usually'  too  weak 
to  be  about  the  house,  and,  for  safet}',  rest  is  essential. 


Interstitial  Nephritis.  323 

Uraemia  is  especifilly  apt  to  develop.  It  manifests  itself 
almost  constantly  in  a  chronic  form,  and  often  ends  life 
b}'  developing  acutely.  Cardiac  thrombosis  and  con- 
sequent embolism  may  be  the  immediate  cause  of  death, 
but  it  is  oftener  uraemia  or  some  complicating  inflamma- 
tion. When  cardiac  weakness  develops,  the  disease 
completes  its  course  nipidl}^ 

It  is  most  important  to  prolong  each  stage  of  the 
disease,  as  danger  to  life  is  greater  and  the  course  shorter 
in  each  successive  one.  Therefore,  as  the  disease  pro- 
gresses, life  is  hurried  more  rapidly  to  a  close. 

Diagnosis.-— W\\QYi  albuminuria  exists,  a  diagnosis  is 
not  ditlicult.  The  abundant  diuresis,  high  arterial  ten- 
sion, and  cardiac  hypertrophy  are  characteristic  of  the 
earl}'  stages  of  the  disease.  In  the  last  stage  the 
symptoms  of  cardiac  exhaustion  and  scanty  urine,  of 
low  specific  gravity,  are  equally  distinctive.  From  sec- 
ondarily contracted  kidne}^  true  cirrhosis  must  be  dis- 
tinguished by  its  history,  and  usually  by  its  less  abun- 
dant albumen  and  less  abundant  evidence  of  fatt}'  change 
within  the  kidnej'. 

Treatment. — Important  indications  for  treatment  are 
to  avert  uraemia  and  cerebral  haemorrhage,  or  other 
common  complication.  These  indications  exist  in  ever}' 
stage  of  the  disease.  There  are  others  that  are  peculiar 
to  each  stage.  There  is  no  specific  which  successfull}^ 
counteracts  the  characteristic  renal  lesion  (connective- 
tissue  hyperplasia),  although,  to  limit  or  cause  resolu- 
tion of  it,  such  drugs  as  the  iodides  of  sodium  or  potas- 
sium, mercurials,  and  the  double  chloride  of  gold  and 
sodium  have  been  used.  I  have  been  disapi)ointed  by 
not  obtaining  positive  good  eflfects  from  them.  Un- 
doubtedly, the  first  two  may  prove  useful  in  the  rare 
cases   of  syphilitic    origin.      I    believe  the  iodides  are 


324  Renal  Inflammations. 

useful  in  renal  cirrhosis  chiefly  b}^  lessening  arterial 
tension  and  b}^  promoting  diuresis,  but  are  of  little  or 
no  use  to  prevent  the  cirrhosis.  The  chloride  of  gold 
and  sodium  may  be  tried,  for  it  is  thought  to  be  decid- 
edly efficacious  by  Bartholow,  Tyson,  and  Purdie.  Q\iick 
results  must  not  be  expected  of  drugs  used  to  meet  this 
indication. 

The  first  step  toward  successful  treatment  is  to  re- 
move the  cause  of  the  disease.  High  living  and  the 
use  of  alcoholics  should  be  forbidden.  Exposure  to 
cold,  dampness,  and  sudden  thermpmetric  changes  may 
aggravate  the  renal  trouble.  The}'  must,  therefore, 
be  avoided  by  change  of  climate  and  hy  careful  clothing. 
In  the  first  and  second  stages  of  the  maladv  life  ma}'  be 
much  prolonged  by  a  permanent  residence  in  equable 
and  balm}'  climes.  Southern  California  is  nearly  an 
ideal  climate.  Many  islands,  like  the  Bermudas  and  the 
Sandwich,  have  similarly  equable  and  balmy  air.  Florida 
and  many  places  in  the  Southern  States  and  on  the 
Mediterranean  coasts  are  also  suitable  winter  climates 
for  those  who  can  make  only  temporary  changes  of  loca- 
tion. The  skin  should  be  protected  by  wool,  so  that 
sudden  thermometric  changes  will  not  be  felt.  Food 
should  not  be  highly  spiced,  or  rich,  or  contain  large 
amounts  of  albumen.  It  must,  howevei-,  be  nutritious 
and  varied.  No  treatment  for  this  disease  is  so  curative, 
or,  at  least,  so  protecting  to  life,  as  a  suitable  diet.  By 
it  the  great  danger  to  life — uroemia — may  often  be 
averted,  and  an  increase  of  cirrhosis  may  be  prevented 
or  delayed  by  limiting  the  amount  of  material  irritating 
to  the  kidneys  which  is  admitted  to  the  blood. 

Whenever  the  daily  excretion  of  urea  falls  below  a 
normal  standard  it  must  be  increased  by  stimulating- 
diuresis,  and  an  accumulation  of  noxious  waste  matter 


Interstitial  Nephritis.  325 

must  be  averted  by  diminisliiiig  the  metamorphosis  of 
iiitrogeiious  mttterial  in  the  system.  Tliis  hist  may  be  ac- 
complished by  regidatiiig  the  diet.  If  unemia  threaten, 
a  nou-albuminoiis  diet  must  temporarily  be  used,  but  at 
other  times  it  need  onl}'  be  simple  and  free  from  an  ex- 
cess of  meat  extractives,  such  as  exist  in  rich  gravies, 
soups,  and  game.  A  modicum  of  albuminous  food  ma}' 
be  used  if  it  is  simply  cooked,  and  so  long  as  nitrogenous 
matter  is  eliminated  in  normal  amounts.  Milk  is  nearl}" 
as  useful  as  in  chronic  parenchymatous  nei)hritis.  To 
stimulate  the  kidneys  when  tlieir  secreting  })o\ver  is 
lessened,  such  salts  as  tlie  citrate  or  acetate  of  potas- 
sium or  sodium,  or  carbonate  of  lithium  should  be  em- 
ployed. Digitalis  and  strophanthus  may  be  used,  but 
in  the  first  and  second  stage  very  temporarily,  for  it  is 
not  desirable  to  increase  arterial  tension  -when  it  can  be 
avoided,  as  it  in  turn  increases  the  heart's  lal)or  and  may 
hasten  exhaustion.  Strophanthus,  in  therapeutic  doses, 
contracts  the  arterioles  throughout  the  bod}-  least,  and 
is  to  be  preferred.  It  is,  therefore,  evident  that  close 
watch  must  be  kept  of  the  quantity  of  urine  and  of 
nitrogenous  matter  that  is  being  voided.  Patients 
should  measiu'e  the  urine  made  b}^  them  in  twenty-four 
hours,  at  least  twice  each  week.  If  it  fall  below  an 
average,  which  each  patient  must  determine  for  himself, 
a  physician's  counsel  should  be  sought.  However,  so 
great  confidence  c.-innot  be  placed  in  measurements 
of  the  dail}'  quantit}'  of  urine  voided  as  in  coincident 
tests  of  the  amount  of  urea  voided;  for  the  nitrogen- 
ous elimination  does  not  alwa3's  fluctuate  directl3'as  tiie 
quantity  of  urine  does.  The  former  may  diminish  much 
more  than  the  latter.  Intelligent  patients  can  be  easily 
taught  to  take  the  urine's  specific  gravity,  as  well  as  to 
measure  its  amounts.     The  table  on  page  326,  which  I 


Renal  Infiammations. 


%  I 


+ 

1 1 


■c    ^ 


^  %    %    S 

-*    gl    3    2 


+ 

o      « 


„I5,     o      «o      o 
"^     §     o     o 


s   g 


2  I 

O  " 


O 


linve  computed,  will  enable  them  to 
determine  when  tliey  are  excreting 
normal  quantities  of  urinary  solids. 

This  table  is  calculated  in  cubic 
centimetres,  and  the  pints  named 
are  approximate  equivalents,  but 
sufficientl}'  near  for  clinical  pur- 
poses. 

In  the  table  the  si)ecific  gravi- 
ties represent  for  the  different 
amounts  of  urine  a  normal  average 
of  35  grammes  of  urea,  and  a  mini- 
mum normal  of  15. 

The  diet  should  be  restricted, 
and  the  kidneys  should  be  stimu- 
lated as  soon  as  the  specific  gravity' 
falls  below  the  "minimum  normal  " 
for  the  amount  of  urine  made  ;  and 
the  patient  should  endeavor  to 
keep  it  at  or  above  the  "  normal 
average."  It  must  be  remembered 
that  the  amount  of  nitrogenous 
matter  voided  varies  with  the  diet. 
For  instance,  according  to  Frank, 
on  a  pure  animal  diet,  51  to  92 
grammes  of  urea  will  be  excreted 
daily ;  upon  a  mixed  diet,  36  to 
38;  upon  a  vegetable  diet,  24  to 
28;  and  upon  a  non-nitrogenous 
diet,  16.  The  amount  eliminated 
daily  is  greater  in  men  than  in 
women,  and  in  different  individuals 
it  varies  much.  Different  observ- 
ers do  not  aoree  as  to  the  normal 


Interstitial  Nephritis.  327 

daily  variation,  and  most  of  them  affirm  that  about  34 
grammes  daily  is  excreted  by  men,  and  25  by  women  ; 
but  15  to  18  may  be  said  to  be  the  minimum  normal. 
And  this  is  a  dangerously  small  amount,  if  a  patient  is 
on  a  rich  meat  diet. 

Hot-air  baths,  which  will  produce  sweating,  can  be 
used  with  advantage  to  relieve  uraemia.  Nothing  else 
is  more  promptl}'  efficacious  in  chronic  uraemia.  Laxa- 
tives are  beneficial  b}^  aiding  to  eliminate  vicariously 
ursemic  poisons,  and  they  help  to  prevent  high  arterial 
tension.  Drastics  may  be  required  for  this  purpose,  but 
their  use  cannot  be  long  continued,  because  the)'  are  ex- 
hausting. The  stools  should,  however,  be  kept  soft,  for 
if  the  rectum  or  intestines  are  distended  with  compact 
faecal  matter  the  pulse  becomes  more  tense  and  the 
labor  of  the  heart  is  increased. 

In  the  first  stage  of  the  disease  all  unnecessary  car- 
diac labor  must  be  avoided,  so  that  its  hypertroph}-  will 
not  be  hastened.  To  maintain  soft  stools,  moderate 
doses  of  Hun3'^adi  Janos  water  or  Rochelle  salts  are 
among  the  best  remedies.  Sometimes  the  persistent  use 
of  calomel,  in  small  doses  (J  to  ^  grnin),  will  keep  the 
bowels  moving  easily  and  promote  better  diuresis,  if  it 
is  lessened. 

In  the  second  stage  uraemia  and  common  complica- 
tions must  be  avoided,  as  in  the  earlier  stage.  Cerebral 
apoplexy  and  other  haemorrhages  are  most  apt  to  occur 
in  this  period  of  the  disease's  course.  The  natural  ter- 
mination of  this  stage  is  cardiac  weakness.  Its  post- 
ponement is  the  special  indication  for  treatment.  The 
sclerotic  changes  which  often  occur  in  the  arteries  of 
various  organs  are  an  important  cause  of  haemorrhage, 
but  they  cannot  be  much  modified  by  medicine.  Brittle 
arteries  will  not  often  break  unless  they  are  unusually 


328  Renal  Inflammations. 

stretched  by  blood  that  is  under  abnormalh^  high  press- 
ure. The  cardiac  h3'pertrophy,  the  renal  sclerosis  and 
consequent  vascular  obstruction,  and  often  the  more 
generalized  obstruction  which  thickening  of  the  arterial 
walls  causes,  constantl}'  keep  the  blood  under  an  ab- 
normally high  pressure.  There  are  many  other  tem- 
porar}'  and  removable  causes  of  high  pressure, — such  as 
undue  physical  or  mental  exertion,  indigestion,  and 
constipation.  Excitement,  anxiet}  ,  or  mental  strain 
of  any  kind  must  be  avoided.  It  is  not  best  to  require 
patients  to  give  up  business  or  all  mental  occupation, 
for  tiieir  stimulus  is  needed  if  the}'  do  not  necessitate 
overexertion,  and  if  the  individuals  are  not  too  weak. 
Absolute  phj'sical  rest  is  not  necessary  or  desirable,  but 
overexertion,  which  is  exhausting,  should  not  be  per- 
mitted. Hurried  and  violent  movements,  such  as  run- 
ning, stair-climbing,  rowing,  or  gymnasium  exercises, 
must  be  avoided.  Occupations  should  be  sought  that 
do  not  require  hurried  movements,  or  heav}^  lifting  or 
other  violent  exertion.  Gentle  exercise,  S3'stematically 
taken,  is  essential  to  maintain  good  muscular  strength. 
Indigestion,  both  in  this  and  the  first  stnge,  must  be 
promptl}'^  treated.  It  is  due  to  slow  digestion,  which 
makes  it  possible  for  abnormal  fermentation  to  take 
place  in  the  undigested  food.  Digestion  may  be  hast- 
ened by  administering  only  such  foods  as  are  easily  di- 
gested, and  \)\  avoiding  an  overloading  of  the  stomach. 
Food  should  be  taken  if  necessaiy  four  or  five  times 
daily  instead  of  three,  and  in  amounts  so  small  that  the 
stomach  will  not  at  one  time  contain  more  tlian  it  can 
quickl}'  digest.  Pepsin  is  useful  in  such  cases.  Slow 
peristalsis  is  oftener  the  cause  of  indigestion  than  dimin- 
ished gastric  ferments,  for  a  little  of  tlie  latter  can 
accomplish    much.       Peristalsis    is    best    increased    b\' 


hiterstitial  Nephritis.  S29 

gentle  general  exercise,  or  by  massage  over  the  bowels, 
and  by  frequent  deep  inhalations  of  fresh  air,  which, 
by  better  oxygenating  and  purifying  the  blood,  invigor- 
ates the  function  of  every  tissue,  and  also  by  tonic 
laxatives  like  cascara  and  aloes.  Abnormal  fermenta- 
tion can  be  best  prevented  b}^  avoiding  such  foods  as 
are  most  readily  attacked  and  decomposed  into  noxious 
substances, — for  example,  fats  and  starchy  foods,  wliich 
are  not  semi-liquid,  granular,  or  easily  made  so, — and  b^^ 
administering  anti-ferments,  such  as  carbolic  acid,  resor- 
ciii,  muriatic  acid,  etc.  •  These  drugs  must  be  used  with 
caution  and  in  small  doses,  as  most  of  tliem  are  elimi- 
nated by  the  kidneys  and  are  irritating  to  them.  A 
dietetic  treatment  is  to  be  preferred  to  a  medicinal  one, 
in  such  cases.  Constipation  must  be  preve;ited,  as  in 
the  early  stage  of  the  disease;  or,  if  it  is  associated 
with  atonic  indigestion,  by  cascara,  or  aloes  in  combi- 
nation with  blue  pill  or  calomel.  Drastics  may  some- 
times be  needed  to  relieve  uraemia.  An  occasional 
gentle  purge  with  salts  is  useful  to  lower  arterial  ten- 
sion when  it  increases.  Arterial  tension  must  be  as 
closely  watched  in  this  stage  as  must  signs  of  renal 
incompetence.  If  arterial  tension  is  perceptibly  increas- 
ing, as  can  be  most  easily  demonstrated  b}^  the  sph^-g- 
mogrnph,  it  should  be  lessened.  This  cannot  always 
be  permanentl}'  accomplished.  A  temporary  lowering 
of  the  pressure  can  be  effected  with  promptness  and 
certainty  b}^  the  nitrites.  A  rapid  lowering  of  pressure 
is  usuall}' not  so  desirable  as  a  prolonged  one;  there- 
fore, the  nitrite  of  sodium  or  potassium  is  the  best  to 
use.  It  can  be  given  in  doses  of  from  1  to  3  deci- 
grammes (2  to  5  grains)  three  or  four  times  daily.  It 
should  not  be  given  oftener  than  is  necessar}^  in  order 
to  accomplish  the  desired  reduction  in  pressure.      Its 


330  Renal  Inflammations. 

persistent  use  is  often  commended,  but  I  do  not  believe 
that  it  is  safe  to  employ  it  for  man\'  days  or  weeks.  It 
lowers  the  arterial  pressure  by  lessening  the  irritabilit}^ 
of  the  vascular  muscles  and  intrinsic  nerves.  In  full 
doses  it  simultaneously  quickens  the  heart's  action.  It 
lessens  the  oxjgen  carrying  power  of  the  blood,  and 
diminishes  the  quantity  of  urine.  The  last  two  modes 
of  action  make  it  contra-indicated  for  continuous  use  if 
there  are  S3^mptoms  of  chronic  uraemia.  It  may  be 
temporarily  employed  to  relieve  uraemia,  for  it  lessens 
the  excitability  of  reflex  centres.  From  its  action  upon 
the  heart  and  tlie  blood-vessels  it  is  evident  that  it 
lessens  the  heart's  strength,  and,  b}'  diminishing  the 
oxygen  carrying  power  of  the  blood,  would,  if  continu- 
ously emplo3'ed,  hasten  fatty  degeneration  both  of  the 
heart  and  the  kidne3S.  While  it  is  an  extremely  valu- 
able remedy-  in  renal  cirrhosis,  it  must  not  be  used  as  a 
part  of  routine  treatment,  but  judicioush'.  Because  of 
the  analogous  action  of  the  iodides  they  can  be  usefully 
emplo3'ed  in  this  disease.  The3^  do  not  produce  so  pro- 
nounced an  arterial  dilatation,  but  it  is  more  prolonged. 
The3'  must  be  given  in  full  doses  (0.5  to  1.5  grammes — 
8  to  20  grains)  if  possible,  and  ma3'  be  used  with  safet3' 
for  a  long  time. 

The  urine  must  be  watched  as  closel3'  in  this  stage 
as  in  the  earlier.  The  same  remedies  ma3'  be  emplo3'ed 
to  stimulate  the  kidneys  to  functional  activit3'.  Digi- 
talis and  other  vaso-constrictors  are  contra-indicated. 
If  some  allied  drug  is  demanded  for  a  short  time, 
strophanthus  is  the  best.  Hot-air  baths  temporaril3' 
increase  blood-pressure,  but  if  uraemia  is  imminent  they 
must  be  used,  and  even  repeated  often.  The3'  should, 
however,  be  used  in  this  stage  of  the  disease  only  when 
it  is  necessar3',  and  onl3'  so  long  as  it  is  necessary.     An 


Interstitial  Nephritis.  331 

abundance  of  pure,  clean  air,  and  frequent  deep  inhala- 
tions of  it,  are  certainly  useful  to  prevent  uraemia  and 
fatty  degeneration  by  maintaining  good  metabolism. 
Inlialation  of  oxygen  may  be  tried,  for  it  is  believed  bj' 
many  to  be  of  value.  It  has  always  disappointed  me  in 
such  cases. 

In  the  third  stage,  when  cardiac  weakness  exists,  a 
different  class  of  agents  must  be  used.     Tlie  chief  indi- 
cation for  treatment  is  to  maintain  the  heart's  strength, 
Tiiere  is  greater  danger  of  uraemia  than   in  the  earlier 
stages.     It  must  be  averted  by  the  same  regimen  and 
treatment.     Arterial  pressure  is  low,  and  digitalis,  con- 
vallaria,  or   strophanthus  may  be  used  with  impunity, 
and  often  are  absolutely  essential.     By  them  the  heart 
can    be,  at   least   temporarily,   strengthened.     Usually, 
degeneration  as  well  as  muscular  exhaustion  causes  the 
heart's  feeble  action.     Iron,  str3-chnia,  quinia,  and  other 
bitters  are  best  calculated   to  stimulate  and   maintain 
healthful  tissue-change,  and,  therefore,  to  avert  danger- 
ous degeneration.     They  must  be  used  persistently,  and 
nsuall}'  combined  with  digitalis.    An  abundance  of  fresh 
air,  deep  inspirations  of  it,  and  very  gentle  active  or 
passive  exercise  are  also  needful.     The  chances  of  suc- 
icessfully  removing  the  cardiac  weakness  are  not  good, 
jfor  when   it  develops  the   blood  is   impoverished,  the 
i muscular  and  nervous  systems  lack  vigor  and  tone,  and 
I  often  the  stomach  digests  food  imperfectly'.     These  con- 
ditions make  it  almost  impossible  to  do  more  than  to 
jtemporaril}' strengthen  the  heart.     The  diet  must  usu- 
;  ally  be  poor,  both  because  digestion  is  not  good  and  in 
order   to    avert    uraemia.      It    should,   however,    be    as 
:  strengthening  and  as  liberal  as  is  possible  under  the  cir- 
I  cumstances.     (Edema  is  a  symptom  in  this  stage  that 
requires  treatment.    Sometimes  aspiration  of  the  pleural 


332  Renal  Inflammations. 

or  pericardial  sacs,  or  incisions  at  the  ankles,  are  neces- 
sar3\  Usualh',  reliance  is  placed  upon  diuretics,  dia- 
phoretics, and  cathartics. 

In  renal  cirrhosis  opiates  are  generall}'  contra-indi- 
cated, since  the}'  lessen  the  urine  and  especially  the 
elimination  of  nitrogenous  waste.  Their  use,  therefore, 
increases  the  danger  of  uraemia.  It  is  especial I3'  neces- 
sary to  bear  this  in  mind  in  treating  inflammator}'  com- 
plications of  the  disease.  If  opiates  are  employed  the 
urine  must  be  examined  daily,  and  they  must  be  discon- 
tinued if  they  materially'  interfere  with  the  renal  func- 
tions. The  persistent  and  very  intractable  diarrhoea 
which  sometimes  occurs  in  this  disease  must  be  treated 
chie%  b}^  astringents,  such  as  tannic  acid,  lead  acetate, 
or  nitrate  of  silver.  Oedema  or  inflammation  of  tlie 
lungs  must  be  treated  as  under  other  circumstances. 

Prognosis. — It  is  scarcely  necessary  to  recapitulate 
the  prognosis  of  this  disease.  If  the  malad}-  is  recog- 
nized in  the  first  stage,  and  if  urpemia  or  intra-craniai 
haemorrhages  are  escaped,  the  chance  of  living  from  five 
to  ten  3-ears  is  good.  It  may  be  possible  to  prolong  life 
even  more  than  this.  If  uriemia  threaten  often,  the 
chances  are  not  good  for  a  long  life.  Tiie  second  stage 
commonl}'  lasts  from  one  to  five  years,  though  it  may 
be  more  prolonged.  The  third  stage  rarely  extends 
over  a  3'ear.  To  treat  the  disease  successful!}'  the  pa- 
tient must  be  instructed  as  to  its  chronicit}',  its  dangers, 
how  their  approach  is  to  be  recognized,  and  regarding 
the  necessity  for  continuous  guidance  b}'  a  physician. 


CHAPTER  XXXIY. 

Suppurative  Nephritis. 

Suppurative  nephritis  is  more  properly  a  surgical 
than  a  medical  disease ;  but,  as  a  diagnosis  is  generally 
demanded  of  the  physician  first,  it  is  appropriate  to 
describe  it  briefly  here. 

Causes. — P3^ogenic  matter  may  gain  access  to  the 
kidneys  through  the  blood  or  the  urinary  channels. 
When  by  the  former,  p3'8emia  or  purulent  endocarditis 
is  oftenest  the  primary  disease.  Rareh',  it  complicates 
other  diseases  that  are  accompanied  b}'  suppuration, 
such  as  d3'senter^^ 

Suppurative  diseases  of  the  urinary  channels,  such 
as  urethritis,  prostatic  suppuration,  C3'stitis,  and  pyeli- 
tis, are  oftener  its  cause.  Much  less  frequently  renal 
suppuration  originates  by  extension  of  inflammation 
from  the  perirenal  tissue,  or  results  from  penetrating 
wounds. 

Anatomy. — The  kidne}^  ma}'  be  enormousl}'  distended 
and  its  tissue  almost  wholl}^  destroyed  and  replaced  by 
pus.  This  is  rare,  except  as  the  result  of  suppurative 
pyelitis.  Usuall}',  the  substance  of  the  kidney  is 
studded  with  minute  abscesses  and  the  organ  is  verj^ 
little  enlarged.  It  may  retain  its  normal  color,  or  be 
mottled.  Abscesses  are  frequently  visible  through  the 
capsule  as  yellow  spots.  Over  them  the  capsule  is  usu- 
ally adherent  to  the  cortex.  On  a  cut  surface  the  ab- 
scesses, if  they  are  of  p3'Bemic  origin,  are  generall}' 
most  abundant  in  the  cortex;  if  they  originate  from 
diseases  of  the  urinary  channels  the  pj^ramids  are  as 

(333) 


334  Renal  Injiammations. 

apt  to  be  extensivel}'  involved  as  the  cortex.  The  ab- 
scesses are  often  miliary-  and  verj'  numerous.  Wlien 
small  they  appear  as  minute  3'ellow  spots,  usually  sur- 
rounded In'  a  zone  of  hyperaemia.  Often,  when  the  sup- 
puration arises  by  extension  from  the  lower  urinar}' 
channels,  the  kidney  seems  striated  by  lines  of  pus  ex- 
tending through  the  pyramids  and  into  the  cortex.  In 
these  cases  the  inflammation  originates  in  the  renal 
tubules.  When  the  pyogeuic  matter  reaches  the  kid- 
ney' b}'  the  arteries,  it  usually  lodges  in  a  small  vessel 
or  o-lomerule.  At  first  a  collection  of  leucocvtes  and 
pus-cells  marks  the  site  of  the  abscess.  As  the}'  accu- 
mulate they  compress  and  destroy  the  neighboring  tis- 
sue. The}^  may  grow  large,  or  coalesce  and  make  cav- 
ities the  size  of  a  cherr}'  or  greater.  Both  kidnevs  are 
frequently"  affected  simultaneously. 

Abscesses  in  the  kidne>',  usuall}-,  sooner  or  later, 
communicate  with  the  uriniferous  tubules,  and  through 
them  empt}'  pus  into  the  urine.  If  tlie  ureters  are  ob- 
structed, as  they  may  be  in  some  cases  of  pyelitis,  pus 
will  not  be  voided  from  the  bod}*.  The  pelvis  of  the 
kidney  will  then  be  converted  into  a  distended  sac  of 
pus,  which  will  enlarge  by  the  destruction  of  the  renal 
substance.  In  this  wa}"  ver}^  large  abscesses  ma}'  be 
formed.  Instead  of  finding  an  exit  through  the  urinary 
channels,  the  pus  verj^  rarel}'  breaks  into  the  peritoneal 
cavity,  or,  after  adhesive  peritonitis  has  bound  the 
kidney  and  intestines  together,  into  the  intestines,  or 
externally  through  the  abdominal  wall,  or  b}-  burrowing 
into  the  pleura  or  lung. 

Symptoms. — Abscess  of  the  kidne}-  ma}'  exist  with- 
out producing  characteristic  sym})toms.  This  is  most 
apt  to  occur  in  septicseniia.  The  symptoms,  which  are  of 
diagno8tic  value,  are  pyuria,  usually  renal  pain,  hectic 


Suppurative  Nephritis.  335 

fever,  and  sometimes  renal  tumor.  When  there  is 
p^Hiria,  it  is  necessary  to  distinguish  that  which  is  due 
to  renal  suppuration  from  suppuration  of  the  lower 
urinar}^  passages.  When  pus  is  formed  in  the  kidney, 
the  urine  contains  a  larger  proportion  of  albumen  than 
when  pus  is  formed  elsewhere  in  the  urinary  tract.  Re- 
nal tube-casts  are  often  found  in  the  urine,  and  rarely 
bits  of  renal  tissue  may  be  discovered  in  it.  The  sudden 
appearance  of  large  amounts  of  pus  in  the  urine  usually 
signifies  the  bursting  of  an  abscess  into  the  urinary 
tract  at  some  point  in  its  course. 

Pain  in  the  kidnej's  may  be  wanting  or  may  be  very 
slight.  It  is  caused  chiefly  by  stretching  the  capsule. 
It  is,  therefore,  commonly  inconsiderable,  except  when 
the  whole  kidney  is  involved,  and  is  greatly  distended 
with  pus.  When  pain  exists,  it  is  aching  or  at  least 
constant  and  dull.  It  is  usually  felt  quite  as  much  in 
front  and  in  the  side  as  in  tlie  back.  Sometimes  the 
passage  of  clots,  shreds  of  renal  tissue,  or  calculi,  when 
they  are  loosened  from  the  kidne3^,  causes  renal  colic. 

The  kidney  can  be  felt  as  a  tumor  only  when  it  is  ver^^ 
much  distended.  It  can  then  be  felt  by  deep  pressure 
upon  the  sides  of  the  abdomen.  The  shape  of  the  kidney 
can  usually  be  outlined  by  the  palpating  hand.  When 
enormously  distended  it  may  almost  fill  one  side  of  the 
abdomen  ;  when  considerably  distended,  fluctuation  may 
be  felt.  Usuall}^,  the  organ  is  too  deeply  located  to 
make  it  possible  to  elicit  this  sign.  When  the  kidney  is 
suflSciently  distended  to  be  felt,  it  is  usually'  evenly  so. 
Rarely,  the  surface  is  made  uneven  by  projecting  ab- 
scesses of  considerable  size.  The  symptoms  of  hectic 
fever  are  present  unless  the  pus  is  perfectly  drained,, 
spontaneously  or  artificially. 

Prognosis. — The  prognosis  of  suppurating  nephritis 


336  Benal  Inflammations. 

is  unfavorable.  RecoveiT  is  possible  if  the  abscess  or 
abscesses  can  be  perfectly  drained.  This  is  rarely,  if 
ever,  accomplished  spontaneously.  When,  as  is  usual, 
there  are  many  small  abscesses,  and  especially  if  the}' 
are  in  both  kidneys,  drainage  b}^  a  surgical  operation  is 
impossible.  Under  such  circumstances  death  is  almost 
inevitable.  The  nature  of  the  primar}'  disease,  when 
there  is  one,  must  be  considered  when  the  chances  of 
recover}'  are  computed. 

Treatment.  —  Treatment  must  be  supporting  and 
symptomatic.  The  essential  of  successful  treatment  is 
the  removal  of  the  pus  and  the  prevention  of  its  re- 
formation. This  may  necessitate  aspiration,  nephrot- 
omy, or  nephrcctom3\  Food  should  be  as  generous  in 
amount  and  variety  as  the  stomach  will  tolerate  and 
utilize.  Renal  irritants  should  be  excluded  from  the 
dietar}',  beverages,  or  medicines  of  those  who  suffer  from 
suppuration  of  the  kidueys.  Anodynes  ma}'  be  needed 
to  relieve  pain.  Tonics  and  haematics  will  be  useful  if 
fever  is  absent  and  convalescence  is  beginning.  Indi- 
gestion may  also  have  to  be  relieved  by  appropriate 
treatment. 


RENAL  DEGENERATION. 


CHAPTER  XXXY. 

Amyloid  Kidney. 

Nature  and  Causes. — This  is  one  of  the  renal  lesions 
often  denominated  Bright's  disease.  It  is  due  to  the 
formation  of  a  chemical  substance  which,  united  with 
the  reual  tissue,  forms  a  new  chemical  body  tliat  destro3's 
the  function  and  structure  of  that  tissue  and  replaces 
it  with  homogeneous  albuminoid  matter. 

Amyloid  kidney  is  commonh'  secondar}'  to  chronic 
suppuration,  but  it  has  been  known  to  develop  in  the 
third  week  after  the  onset  of  acute  suppuration.  The 
pus  may  be  formed  in  any  part  of  the  bod}'.  Often 
amyloid  kidne}'  accompanies  chronic  suppuration  of  the 
lungs  or  joints.  It  may  follow  syphilis  and  tubercu- 
losis, even  when  these  diseases  do  not  cause  suppura- 
tion. Rarely,  it  has  been  observed  in  association  with 
chronic  intermittent  fever.  Oftener  it  accompanies 
chronic  nephritis,  cancer,  leucocythsemia,  and  other 
cachectic  conditions.  Very  rarel}',  it  occurs  without 
discoverable  cause.  Amyloid  infiltrations  are  observed 
oftener  in  men  than  in  women,  and  oftenest  between  the 
ages  of  12  and  50. 

Anatomy. — When  amyloid  changes  are  not  extensive, 
the  kidney  does  not  change  in  sizie  or  appearance.  If 
they  are  sufficiently  extensive  to  produce  appearances 
that  are  characteristic,  the  kidney  is  large,  pale,  firmer, 
and  heavier  than  normal.     The  surface  is  smooth,  and 

15  P  (337) 


338  Renal  Degeneration. 

the  capsule  is  easily  removable.  The  cut  surface  of  the 
kidney  presents  the  same  ph3'sical  characters.  Upon  it 
man}'  glomeruli  are  visible  as  gray,  opaque  dots,  and 
here  and  there  streaking  the  medulla  and  cortex  similar 
gray  lines  are  observable.  If  absolution  of  iodine  is 
poured  over  the  surface,  the  gra^' matter  becomes  reddish 
brown  and  is  strongly  contrasted  with  the  rest  of  the 
tissue,  which  is  yellowish.  The  kidney  ma}-  be  mottled 
with  yellow  or  ma}'  be  ditfusely  3'ellowish.  Tlie  color  is 
the  result  of  fatt}'  degeneration.  If  a  section  is  ex- 
amined microscopically,  the  capillar}'  tufts  in  the  affected 
glomerule  will  be  found  to  be  partly  or  wholly  homo- 
geneous and  semi-translucent.  The  vessels  are  swollen 
and  impermeable  to  the  blood.  Elsewhere  in  the  me- 
dulla the  arteries  and  capillaries  are  seen  to  be  similarly 
affected.  If  amyloid  deposits  are  very  numerous  they 
will  occur  extensively  in  the  vessels  and  may  be  in  the 
basement  membrane  of  the  tubules.  The  glomerular 
capillaries  and  afferent  vessels  are  first  involved.  Fatty 
degeneration  of  the  renal  epithelium  is  associated  wMth 
amyloid  infiltration,  but  the  fatty  degenerative  and 
amyloid  changes  bear  no  constant  ratio  to  one  another. 
Often  the  fatt}''  cells  are  cast  off  and  disintegrate.  They 
partly  fill  some  tubules,  or  granular  nuitter  resulting 
from  them  does.  Hyaline  casts  and,  less  frequently, 
amyloid  casts  are  observable  in  the  tubules.  Some- 
times the  connective  tissue  is  slightly  infiltrated  with 
round-cells.  The  evidences  of  fatty  degeneration  and 
inflammation  may  be  more  noticeable,  both  clinically  and 
anatomically,  than  those  of  amyloid  infiltration.  In 
such  cases  the  amyloid  disease  may  escape  notice  unless 
it  is  sought  for  closely.  Other  organs,  especially  the 
spleen  and  liver,  are  apt  to  be  similarly  affected. 

Symptoms.  —  As  amyloid  kidney    is   usually  a  sec- 


Amyloid  Kidney.  339 

oiidary  disease,  its  S3'mptoms  are  associated  with  those 
of  the  primary  trouble.  Anaemia,  emaciation,  and  weak- 
ness are  usiiallj'^  due  both  to  the  renal  and  the  primary 
disease.  Anasarca  is  almost  invariabl}^  present,  but 
exists  to  a  variable  degree.  It  is  sometimes  great  and 
sometimes  slight.  It  may  develop  early  or  late,  and  is 
not  correlated  in  degree  with  the  extent  of  amyloidosis. 
En  the  same  case  tiie  urine  often  varies  greatly  in  amount. 
It  ma}'  be  much  increased,  but  is,  [)erhaps,  oftener  normal 
or  a  little  diminished.  Toward  the  end  of  life  it  is 
usually  greatly  diminished.  It  is  peculiarly  clear  and 
drops  ver}'  little  sediment  when  it  stands.  It  is  acid. 
Its  specific  gravity  varies  from  1005  to  1015.  In  the  sedi- 
ment, h3'aline  and,  rarel}',  amyloid  casts  are  observable. 
Sometimes  granular  casts,  a  few  oil-droplets,  and  grnnu- 
lar  or  fatt}^  epithelial  cells  are  seen.  The  urine  contains 
a  large  amount  of  albumen,  although  in  the  rarest  cases 
the  latter  is  absent.  Urea  is  usuall}'  diminished  in 
nmount,  but  less  so  than  in  nei)hritis.  Although  the 
vessels  of  the  kidneys  and  other  organs  are  much  ob- 
structed, the  heart  is  rarely  enlarged.  The  s[)leen  and 
liver  are  commonly  much  enlarged.  The  latter  can 
often  be  felt,  beneath  the  ribs,  to  be  unusuall}^  firm  and 
smooth.  . 

Uraemia  is  rare  in  simple  amyloid  kidney.  As  ex- 
tensive fatty  degeneration,  or  true  chronic  nephritis,  is 
frequently  associated  with  amyloid  kidney,  the  chnr- 
acteristic  symptoms  of  the  hitter  may  be  modified  and 
obscured  by  the  accompanying  diseases. 

Respiration  and  bodil}'  temperature  are  not  chnnged 
by  the  renal  disease.  The  nppetite  and  the  power  to 
digest  vary  greatl}'.  Usually,  they  are  diminished,  and 
consequently  there  is  evidence  of  slow  digestion  Often 
there  is  diarrhoea,  which  is  persistent   and    not  easily 


340  Renal  Degeneration. 

controlled.  It  ma}'  be  due  to  intestinal  catarrh,  ulcer- 
ation, or  amyloid  change  in  the  arteries  of  that  organ, 
or  to  all  these  lesions  combined. 

Death  may  be  due  to  intercurrent  inflammations  of 
serous  sacs  or  lungs,  but  oftenest  to  marasmus.  The 
duration  of  the  disease  is  variable.  Its  average  is  one 
or  two  years.  It  is  fatal  almost  with  unirormit3\  Re- 
cover}^ is  supposed  rarely  to  have  occurred. 

Diagnosis. — A  diagnosis  is  frequently  difficult  or 
impossible.  If  there  is  a  good  cause  for  amyloid  dis- 
ease, and  if  there  is  an  enlarged  spleen  and  liver,  abund- 
ant albuminuria,  a  normal  or  nearly  normal  quantity  of 
clear  urine  of  low  specific  gravit}',  its  existence  is  prob- 
able. It  can  be  distinguished  from  acute  nephritis  by 
the  small  amount  of  urine  which  accompanies  the  latter, 
its  high  specific  gravity',  and  its  cloud3^  and  reddish 
color.  Blood  is  xQvy  rarely  present  in  the  urine  from 
am3^1oid  kidney's.  From  chronic  parenchymatous  nephri- 
tis, amyloid  kidney  can  be  distinguished  b}'  the  smaller 
amount  of  urine,  b}^  its  greater  turbidit}",  and  b}'  its 
higher  specific  gravity  in  the  former.  From  renal  cir- 
rhosis it  is  distinguishable  b}'  the  larger  flow  from  the 
former  of  limpid  urine  of  low^  specific  gravit3%  contain- 
ing onl}'  traces  or  small  amounts  of  albumen. 

Treatment. — Treatment  must  be  prophylactic,  symp- 
tomatic, and  supporting.  Abscesses  must  be  drained  ; 
syphilis  or  intermittent  fever  must  be  cured  in  order  to 
prevent  the  extension  of  the  amyloid  deposits.  Other 
primary  diseases  must  be  removed  if  possible.  (Edemas 
may  require  removal ;  indigestion  and  diarrhoea  may 
need  treatment.  If  the  functions  of  the  stomach  and 
of  the  bowels  are  much  disturbed,  it  is  impossible  to 
properl}'  nourish  a  patient.  When  these  organs  act 
well  the  nourishment  should  be  abundant  and  highly' 


Amyloid  Kidney.  341 

nutritious.  The  elimination  by  the  kidneys  of  nitrog- 
enous matter  is  usually  so  perfect  that  meat  and  eggs 
cnn  be  eaten  without  danger.  Food  should  be  so  pre- 
pared and  so  given  that  digestion  will  not  be  overtaxed 
or  impaired.  There  is  no  medicinal  treatment  especially 
adapted  to  amyloidosis. 


DISORDERS  OF  THE  RENAL  PELVIS. 

CHAPTER  XXXVI. 

Nephrolithiasis. 

Causes  and  Symptoms. — When  calculi  form  in  the 
kidne}'  or  in  its  pelvis  the  condition  is  called  nephro- 
lithiasis. Calculi  vary  in  size  from  tine,  sand-like  particles 
to  equal  a  hen's  egg.  When  small  the}^  nre  usually  verj- 
numerous.  Their  number  generallj'  varies  inverseh'  to 
their  size.  The}'  are  commonly  rounded  and  smooth,  but 
ma}'  be  acicular,  faceted,  or  noduled.  They  are  usually 
composed  of  uric  acid  and  urates.  They  ni;iy  be  formed 
of  oxalate  or  carbonate  of  lime,  or  of  phos[)hates,  or  very 
rarely  of  cystin,  xanthin,  or  indigo.  Calculi  differ  in 
hardness  and  color  according  to  their  composition. 
Uratic  stones  are  usually  brownish  or  reddish  brown. 
Calcareous  calculi  are  often  very  hard.  Renal  stones 
are  frequently  of  mixed  composition.  The  small  ones 
usually  exhibit  a  crystalline  fracture.  The  larger  ones 
are  more  granular.  They  may  be  laminated.  The  various 
layers  may  have  the  same  or  a  different  composition. 
Calculi  are  supposed  to  form  around  a  nucleus,  which 
may  be  a  crystal  or  a  few  epithelial  cells,  or  a  clot  of 
mucus,  or  bacteria.  Calculi  often  form  in  the  kidney's 
pelvis.  Renal  sand  may  be  deposited  in  the  tubules  or 
even  in  the  intertubular  connective  tissue.  Upon  the 
cut  surface  of  a  kidney  it  may  produce  reddish  stria* 
through  the  medulla  and  cortex.  It  will  cause  a  knife 
to  grate  as  it  cuts  the  organ.  Lnrger  calculi  may  also 
(342) 


Nephrolithiasis.  343 

be  deposited  in  the  renal  substance,  but  oftener  they  are 
found  in  the  pelvis  or,  partly  imbedded  in  the  kidnej^, 
protrude  into  tlie  pelvis. 

The  state  of  the  blood,  or  the  condition  of  metabol- 
ism in  the  kidney  or  generally,  which  causes  their 
formation,  is  not  understood.  It  has  been  observed  that 
they  form  oftenest  in  childhood  and  old  age.  They  have 
been  seen  in  infants  who  died  a  few  da^s  after  birth. 
Thej^  occur  oftener  in  men  than  women.  Sedentary 
habits  and  high  living  seem  to  predispose  to  them. 
Occasionally,  there  seems  to  be  an  inherited  predispo- 
sition to  their  formation.  There  are  geogra[)hical  areas 
where  nephrolithiasis  is  a  common  disease,  and  others 
where  it  is  extremely  rare.  The  use  of  water  that  is 
strongly  calcareous  predisposes  to  the  formation  of  lime 
calculi.  The3^  sometimes  form  in  old  age,  when  lime  is 
re-absorbed  from  bones,  and  in  osteomalacia.  Pyelitis, 
and  especially'  if  urinary  decomposition  occur  with  it, 
is  often  accompanied  by  the  formation  of  calculi.  Gout 
and  the  uric-acid  diathesis  are  frequently  complicated 
by  nephrolithiasis. 

Calculi  may  exist  in  the  kidney  or  its  pelvis  for  a 
long  time  without  causing  an  appreciable  disturbance. 
Nor  does  the  gravity  of  the  symptoms  which  the}'  may 
produce  bear  any  relation  to  their  number  or  size. 
They  frequently  cause  pyelitis  (see  page  350),  renal 
haemorrhage,  inflammation,  nnd  colic.  When  a  calculus 
obstructs  permanently  a  ureter,  it  may  cause  h3dro- 
nephrosis. 

Calculous  pyelitis  is  nsually  diffuse,  but  may  be  cir- 
cumscribed. Ulcers  niMy  be  caused  b}^  it,  and  lead  to 
perforation  and  perirenal  inflammation,  or  to  commu- 
nication with  the  abdominal  cavit}',  or  the  intestines. 
Haematuria  is  a  common  symptom.     It  varies  much  in 


344  Disorders  of  the  Renal  Pelvis. 

severity,  but  usually  is  repeated  if  it  happen  at  all.  It 
often  occurs  when  a  patient  stands  or  walks  far,  and 
ceases  when  he  is  quiet,  or  occurs  only  after  severe  or 
protracted  labor.  The  blood  is  usually-  intimatelj- 
mixed  with  the  urine.  Clots  maj'  be  passed.  Cylin- 
drical ones  are  casts  of  the  ureters. 

Frequentl}^  attacks  of  nausea  and  even  vomiting  are 
the  result  of  reflex  irritation  b}^  renal  calculi.  Quite  as 
often  frequent  urination  and  vesical  tenesmus  are  pro- 
duced by  them.  Inflammation  of  the  kidne}^  is  caused 
by  calculi.  They  are  common  causes  of  suppurative, 
less  frequentl}'  of  chronic,  nephritis.  If  they  produce 
chronic  renal  inflammation,  it  is  especially  apt  to  be  of 
the  interstitial  form. 

Renal  colic  and  the  passage  of  calculi  are  the  most 
characteristic  symptoms  produced  b}^  stones  in  the 
kidney.  The  colic  often  has  an  abrupt  onset.  Intense 
pain  develops  at  once.  Less  frequentl}'  the  pain  grad- 
uall}'  intensifies.  If  ver}'  intense,  the  symptoms  of  col- 
lapse ma}'  develop  rapidh*.  The  patient  will  then  be 
extremely  prostrate,  almost  speechless,  his  pulse  quick, 
small,  and  soft,  and  his  skin  usuall}' cold  and  clamm3\ 
When  the  pain  is  intense  it  cannot  alwa3S  be  located, 
but  is  described  as  a  severe  abdominal  cramp.  Oftener 
it  begins  over  one  of  the  ureters  and  then  becomes  dif- 
fused over  the  abdomen.  The  colic  is  usuall}^  accom- 
panied 1)3'  pains  that  extend  into  the  groin  and  testicle, 
or  into  the  thigh  on  the  side  affected.  In  milder  cases, 
a  stead3',  teasing  pain  will  be  felt  in  the  region  of  one 
kidney,  or  in  the  loin,  which  gradually  shifts  to  the  re- 
gion of  the  ureter,  and  is  felt  to  move  downward  toward 
the  bladder.  The  pains  are  paroxvsmal,  or,  if  constant, 
become  intense,  paroxysmall3'.  The  pain  is  undou])tedlv 
due  to  a  spasm  of  the  ureter,  and  is  a  true  colic.    A  suf- 


Nephrolithiasis.  345 

ferer  from  it  cannot  rest,  but  walks  the  floor,  or  tosses 
constantly  upon  a  bed.  Yer}^  nervous  persons  have  been 
thrown  into  convulsions  by  it.  Nausea,  and  frequently 
vomiting,  accompanies  these  attacks.  In  many  eases, 
the  vesical  tenesmus  is  considerable.  The  pain  may 
cease  suddenly  Avlien  the  stone  drops  into  the  bladder. 
The  cause  of  these  symptoms  is  demonstrated  if  stones 
are  afterward  passed  -from  the  bladder,  or  discoverable 
in  it.  If  the  calculi  are  sand-like  there  may  be  little 
pain,  or  the  attacks  may  be  mild.  Vesical  tenesmus  is 
a  common  symptom  even  in  the  mildest  cases. 

Renal  colic  must  be  differentiated  from  other  ab- 
dominal colics  b}"  the  location  of  the  pain,  the  extension 
of  it  to  the  groin,  testicle,  or  thigh,  and  usually  by 
simultaneous  vesical  tenesmus.  It  is  confirmed  bj-  dis- 
covering the  calculus.  It  is  distinguished  from  hepatic 
colic  by  the  greater  tendency  in  the  latter  for  the  pain 
to  radiate  upward  toward  the  heart  or  shoulder,  and 
b}'  its  location  just  to  the  right  of  the  epigastrium,  and 
by  subsequent  jaundice,  or  by  the  discovery  of  bile- 
stones  in  the  stools. 

The  symptoms  of  hydi^onephrosis  are,  first,  those  of 
renal  tumor.  If  the  kidne}'  is  much  distended,  it  can 
be  felt  through  the  abdominal  walls  and  outlined  by  a 
palpating  hand.  An  area  of  resonance  usually  sepa- 
rates it  from  the  liver.  Dullness  and  tumors  of  the  latter 
move  with  deep  respiration,  but  renal  tumors  do  not. 
An  enlarged  kidney  can  be  distinguished  from  an 
enlarged  spleen,  because  the  latter  usually  enlarges 
upward  and  outward,  and  may  cause  a  lateral  promi- 
nence of  the  lower  ribs  ;  but  the  former  enlarges  down- 
ward and  forward,  and  causes  a  prominence  of  the 
anterior  abdominal  wall.  When  the  kidne}'  is  enlarged 
the  spleen  can,  by  percussion,  be  outlined  in  its  normal 


346  Disorders  of  the  Renal  Pelvis. 

place  and  demonstrated  to  be  independent  of  the  renal 
tumor.  It  can  be  distinguished  from  gastric  tumor  by 
the  movability  of  the  latter  when  the  stomacli  is  more 
or  less  distended,  and  from  faecal  tumors  by  their 
removal  (as  is  usually  possible)  by  free  purgation. 
From  ovarian  tumors  it  must  be  distinguished  b}'  the 
histor}^  of  their  development  upward  out  of  the  pelvis. 
The  latter  are  usuallj^  in  direct  contact  with  the  abdom- 
inal wall,  and  produce  an  area  of  complete  dullness. 
Renal  tumors,  except  when  ver^^  large,  are  separated  b}- 
loops  of  intestine  from  the  abdominal  wall,  and  cause 
only  relative  dullness.  The  tumor  produced  bj^  hydro- 
nephrosis is  usuall}^  not  very  great,  although,  in  excep- 
tional cases,  it  ma}'  fill  nearlj'  half  of  the  abdomen.  It 
is  often  somewhat  uneven.  The  prominent  parts  cor- 
respond to  the  dilated  calices.  When  such  a  small 
tumor  is  discovered,  hydronephrosis  must  be  differen- 
tiated from  solid  renal  tumors  b}'  demonstrating  fluctua- 
tion of  it,  and  from  other  fluid  tumors,  such  as  abscess 
and  echinococcus.  In  echinococcus  hydatids  must  be 
sought  in  the  urine.  In  abscess  the  symptoms  of  hectic 
fever  must  be  expected.  The  discomforts  which  ab- 
dominal tumors  produce  are  usuall}^  present,  especial I3' 
if  the  renal  tumor  is  large.  The}'  are  :  abdominal  dis- 
tension, weight  and  dragging,  dyspnoea  from  pressure 
upon  the  diaphragm,  or  constipation  from  pressure 
upon  the  intestines.  Gastric  symptoms,  such  as  nausea 
and  vomiting,  may  arise  reflexl}'.  Rarely,  a  distended 
renal  capsule  has  been  known  to  rupture  and  iiermit 
the  retained  fluid  to  escape  into  the  peritoneum,  which 
uniformly  causes  acute  peritonitis.  When  113'dronephro- 
sis  is  slight,  it  may  not  be  discoverable,  or  may  be 
easily  overlooked,  unless  there  is  a  histor\'  of  sudden 
obstruction  of  a  ureter.     The  anatomical  changes  con- 


Nephrolithiasis.  347 

sist  in  a  distension  of  the  renal  pelvis,  a  compressing  of 
the  i)yramids,  distension  of  the  calices,  a  slow  atrophj' 
of  the  renal  substance,  which  is  replaced  or,  in  extreme 
cases,  represented  by  a  small  amount  of  connective 
tissue.  It  must  be  remembered  tliat  hydronephrosis 
ma3'  be  caused  in  otlier  ways  than  b}'  lithiasis.  The 
nreters  mny  be  congenitally  narrow,  or  compressed  by 
tumors,  or  twisted;  or  there  maj-  be  obstruction  to 
urination  at  the  neck  of  the  bladder  or  in  the  nrethrn. 
In  the  latter  cases  both  kidney's  are  liable  to  distension. 
If  a  hydronephrosis  can  be  diagnosed,  it  must  be  treated 
surgical!}'.  Its  cause  ma}-  be  removed,  or  the  entire  kid- 
nej-  m;iy  be  taken  away.  Aspiration  for  diagnostic  pur- 
poses is  not  safe,  for  peritonitis  has  resulted  from  it. 

Lithiasis  rarelj'  produces  a  renal  tumor  by  the  accu- 
mulation of  stones  in  the  kidney's  pelvis,  or  by  the 
formation  of  a  very  large  one  that  will  distend  it. 
When  thus  imi)acted,  stones  produce  a  hard,  nodular 
tumor  of  moderate  size.  Its  location  and  sometimes 
obstruction  of  a  ureter,  or  the  histor}'  of  former  rennl 
colic,  or  the  passage  of  sand  or  gravel,  make  probable 
the  difficult  diagnosis  of  such  lithiasis. 

Treatment. — The  indications  for  treatment  in  nephro- 
lithiasis are  the  removal  of  stones  and  the  prevention 
of  their  reformation.  It  has  not  been  demonstrated 
that  stones  of  any  size  can  be  dissolved  by  medicines 
which  are  administered  by  the  mouth.  They  can  onl}- 
be  removed  by  an  operation,  and  this  is  onl}-  justifiable 
when  the  stones  are  provocative  of  other  renal  lesions, 
such  as  dangerous  renal  haemorrhage,  or  pyelitis,  or 
hydronephrosis.  When,  as  oftenest  happens,  stones 
are  passed  and  the  second  ifidication  for  treatment  is 
the  essential  one,  we  ma}'  hope  for  a  reasonable  clegree 
of  success  from  proper  113'giene  and  medicinal  treatment. 


348  Disorders  of  the  Renal  Pelvis. 

If  the  culculi  are  composed  of  uric  acid  or  acid 
urates,  a  mixed  diet  should  be  prescribed  that  shall 
contain  a  moderate  or  minimum  amount  of  nitrogenous 
matter,  and  exercise  and  frequent  deep  inspirations  of 
fresh  air  shoukl  be  assured  to  make  metabolism  active 
and  complete.  Alcoholics  should  be  interdicted,  as 
their  stead>^  use  prevents  perfect  tissue-change  and 
promotes  the  accumulation  of  waste  in  the  system. 
Pure  water  should  be  taken  freel}^,  that  the  tissues  ma}^ 
be  well  washed  and  all  soluble  matter  removed.  The 
water  should  be  as  free  from  mineral  matters  as  pos- 
sible, that  its  dissolving  power  maj"  be  as  great  as 
possible;  or  it  should  contain  lithium.  Lithium  and 
potassium  salts  can  be  given  in  copious  draughts  of 
water,  as  the}^  energize  oxidation,  and,  therefore,  make 
more  perfect  tissue-change.  Therefore,  urea  will  be 
formed  in  larger,  and  uric  acid  in  smaller,  amounts. 
Lithium  also  unites  with  uric  acid  and  forms  a  very 
soluble  compound.  In  these  wa3's,  an  overproduction 
of  uric  acid  will  be  prevented,  and  what  is  formed  easilj- 
removed  with  the  urine.  Yichj',  lithia-waters,  or  such 
salts  as  the  acetate  or  citrate  of  potassium  or  carbonate 
or  benzoate  of  lithium,  are  conimonl}^  prescribed.  The 
benzoates  are  especially'  useful,  for  they  convert  uric 
acid  into  soluble  hippurates.  The  benzoate  of  lithium 
or  sodium  can  be  given  in  doses  of  from  0.5  to  LO 
gramrrie  (10  to  15  grains). 

The  oxalates  which  ma}'  form  calculi  are  chiefly 
produced  from  such  vegetables  as  rhubarb,  sorrel,  toma- 
toes, tea,  spinach, cabbage,  and  celer}'.  Their  use  must, 
therefore,  be  forbidden.  Alkaline  diuretics  nre  now 
useless.  The  vegetable  ones,  such  as  stigmnta  maidis 
and  uva  ursa,  are  often  apparentl}'  efficacious.  They 
can  be  given  as   fluid  extracts,  in  doses  of  from  1  to  4 


Nephrolithiasis.  349 

cubic  centimetres  (^  to  1  drachm).  Water  should  be 
taken  freely. 

Phosphatic  precipitates  in  the  kidney  can  be  pre- 
vented by  maintaining  the  urine  acid.  A  meat  diet 
will  accomplish  this  in  many  persons,  or  acids  can  be 
given  by  the  stomach.  Dilute  nitro-muriatic  is  oftenest 
used  in  doses  of  5  to  10  minims,  or  dilute  lactic  in 
doses  of  from  2  to  4  cubic  centimetres  (|  to  1  drachm). 

Wlien  calculi  cause  colic,  the  pain  must  be  lessened 
by  opiates,  or  by  anaesthetics,  such  as  chloroform  or 
ether.  It  must  be  remembered  that,  as  in  other  cases 
of  severe  pain  which  may  suddeidy  cease,  the  anodynes 
and  anaesthetics,  if  giveii  in  very  large  doses,  may  pro- 
duce fatal  or  dangerous  poisoning;  for,  so  long  as  pain 
is  intense  the  large  doses  may  not  subdue  it,  although 
they  prove  toxic  when  it  ceases.  The  discomfort  which 
accompanies  a  mild  colic  or  the  passage  of  sand  can 
often  be  mitigated  by  sinapisms  and  b\^  heat  applied 
externall}'.  If  calculi  are  slow  in  passing  through  the 
ureters,  massage  can  be  practiced  over  them,  and  atropia 
and  strychnia  can  be  given,  as  they  are  supposed  to 
stimulate  more  vigorous  contractions  in  muscular 
structures,  such  as  the  ureters. 

Renal  haemorrhage  is  best  checked  by  rest,  by  cold 
applications  over  the  kidneys,  by  ergot,  gallic  acid,  and 
acetate  of  lead. 


CHAPTER  XXXYII. 

Pyelitis. 

Cause. — P3^elitis  is  an  inflammation  of  the  pelvis 
of  the  kidne}^  It  may  be  catarrlial,  or  purulent,  or 
lisemorrhagic.  It  is  commonl}'  a  secondaiy  disease. 
Occasional  cases  are  met  with  for  which  no  cause  can 
be  assigned.  Some  of  them  follow  exposure  to  cold. 
Infectious  diseases,  such  as  typhoid,  small-pox,  and 
P3'8emia,  are  often  associated  with  mild  catarrhal  i)3^e- 
litis,  whose  existence  is  only  demonstrated  upon  the 
post-mortem  table,  for  the  symptoms  of  the  primary 
disease  mask  those  of  pyelitis.  It  may  be  provoked  by 
such  drugs  as  cantharides,  copaiba,  and  turi)entine. 
Obstructions  in  the  urinary  tract  often  produce  the 
lesion.  For  example,  compression  of  the  ureters  by  a 
pregnant  uterus  or  other  abdominal  tumor  may  cause  it. 
In  sucli  cases,  there  is  also  more  or  less  of  hydronephro- 
sis. Oftenest  pyelitis  arises  by  extension  of  inflamma- 
tion from  other  parts  of  the  urinary  tract,  or  by  irrita- 
tion from  foreign  bodies  within  the  i)elvis.  More  or 
less  pyelitis  is  commonly  associated  with  the  various 
forms  of  nei)hritis.  Cystitis  very  often  causes  pyelitis, 
and  urethritis  may  do  so.  The  foreign  bodies  which 
csiuse  it  are  usually  calculi.  Clots  and  parasites  may 
also  produce  it. 

Anatomy. — The  ]^elvis  of  the  kidney  ma}-  be  acutely 
or  chronically  inflamed.  When  acutely,  it  may  be  red- 
dened diffusely  or  only  in  patches.  The  mucous  mem- 
branes and  submucosa  become  swollen,  and  mucus, 
desquamated  epithelium,  and  some  round-cells  adhere  to 
(350) 


Pyelitis.  351 

the  surface  or  mix  with  the  fluid  contents  of  the  pelvis. 
If  the  inflamniiition  is  chronic,  the  lining  of  the  pelvis  is 
often  brownish  or  grayish  in  color.  The  contents  may 
be  the  same  catarrhal  products  as  in  acute  pyelitis. 
Haemorrhage  may  occur  in  either  acute  or  chronic 
pyelitis,  and,  when  it  does,  often  causes  extravasation 
beneath  the  epithelium  and  subsequent  pigmentation  of 
the  mucosa  and  submucosa.  Purulent  inflammation  is 
not  uncommon.  It  usually  is  the  result  of  extension 
of  inflammation  from  the  bladder.  In  purulent  pyelitis 
the  kidneys  are  usually  sooner  or  later  involved.  (See 
page  333.)  The  whole  kidney  may  be  destroyed  or 
transformed  into  a  large  abscess.  Usuall3%the  pelvis  is 
distended  when  it  supi)urates.  Instead  of  diffuse  suppu- 
ration, ulcers  may  form  and  may  penetrate  the  capsule 
and  cause  perinephritis  or  peritonitis. 

Symptoms. — A  characteristic  course  cannot  be  de- 
scribed for  p3'elitis,  because  it  is  usually  secondary  to 
other  diseases.  Acute  cases  are  often  unrecognized. 
Recovery  may  occur  in  some. 

Frequentl}',  pain  is  complained  of  in  the  region  of 
the  kidneys.  It  is  a  feeling  of  tension  ornehing  Often 
it  is  associated  with  pain  in  the  testicle  or  perineum,  or 
with  frequent  urination  and  straining.  The  passage  of 
calculi  or  clots  may  cause  renal  colic.  The  urine  is 
usually  acid  and  of  normal  specific  gravity.  It  con- 
tains an  excess  of  mucus  and  generally  some  pus;  it 
may  contain  much  of  it.  Under  the  microscope,  if  there 
is  pyelitis,  besides  pus-cells,  triangular  and  tailed  epithe- 
lial cells  can  commonlj'  be  seen.  The  latter  are  often 
regarded  as  quite  pathognomonic  of  pyelitis,  but  similar 
cells  have  occasionally  been  found  in  the  urine  as  the 
result  of  cystitis.  Blood  in  abundance  is  rnreh'  ob- 
served, except  when  pyelitis  results   from  cnlculi.     If 


352  Disorders  of  the  Renal  Pelvis. 

the  kidney  is  also  involved,  casts  of  renal  tubules  can 
usually  be  found  in  the  urine.  If  fever  exist,  it  is 
commonly  caused  by  the  primary  disease,  but  it  may 
be  due  to  suppurative  pyelitis.  Emaciation  and  other 
S3'mptoms  are  produced  chiefly  b}'  the  other  diseases 
which  pyelitis  accompanies,  but  ma}'  also  be  due  to  sup- 
purative pyelitis.  Headache,  delirium,  and  coma  may 
be  due  to  ammonsmia  from  the  absorption  of  ammonia 
from  decomposed  urine  in  the  bladder  or  renal  pelvis. 

Diagnosis. — It  is  evident  that  a  diagnosis  is  often 
impossible.  If  the  existence  of  calculi  or  of  some  other 
renal  affection  can  be  demonstrated  that  may  cause 
P3'elitis,  and  if,  at  the  same  time,  in  acid  urine  tailed 
epithelial  cells  can  be  found,  a  positive  diagnosis  can  be 
made.  It  is  especiall}^  diflScult  to  distinguish  pyelitis 
when  there  is  cystitis. 

Treatment. — Treatment  must  be  prophylactic  and 
symptomatic.  For  example,  if  cystitis  is  cured,  or  if 
calculi  are  removed,  the  p^^elitis  may  be  recovered  from. 
Pain  must  be  relieved  by  opiates.  Counter-irritants, 
cups,  or  leeches  over  the  kidne3's  will  often  relieve  the 
aching.  It  is  especiall}^  desirable,  when  there  is  slight 
catarrhal  pyelitis,  to  prevent  urinar\'  fermentation 
within  the  kidne}^,  or  to  lessen  it,  if  it  exist.  For  this 
purpose,  such  antiseptics  as  resorcin,  acidum  salicyli- 
cum,  and  salol  are  the  most  useful.  They  should  be 
given  b}'  the  mouth,  in  as  full  doses  as  are  well  borne. 
Of  these,  salol  is  the  best  tolerated  and,  perhaps,  the 
most  useful.  After  it  is  decomposed  b}^  the  alkaline 
juices  in  the  duodenum  into  salic3iic  and  carbolic  acids, 
the  latter  are  eliminated  b}'  the  kidneys.  To  limit  the 
formation  of  pus,  oil  of  sandal-wood,  copaiba,  and 
similar  preparations  are  often  recommended.  The3' 
should  be  used  with  care,  for  pyelitis  ma3^  be  produced 


Pyelitis,  353 

or  aggravated  by  them.  When  judiciously  employed, 
they  often  lessen  the  amount  of  pus  formed.  If  sup- 
puration is  extensive,  surgical  treatment  may  be  neces- 
sary. The  suppurating  pelvis  ma}^  be  drained,  washed, 
and  dressed  as  an  abscess,  or  the  entire  kidney  may 
have  to  be  removed.  The  last  procedure  is  indicated 
when  the  renal  capsule  is  much  distended  with  pus  and 
the  renal  tissue  is  mostly  destroyed. 

In  pyelitis  food  should  be  simple,  nutritious,  and 
free  from  renal  irritants.  Tlierefore,  alcoholics  and  food 
that  is  strongly  spiced  should  be  forbidden.  Milk  and 
milk  foods  are  especially  appropriate. 

Prognosis. — Mild  cases  usually  recover  in  one  or  a 
few  weeks.  Suppurative  pyelitis  that  has  not  involved 
the  kidney  extensively  may  be  recovered  from.  If  very 
chronic,  or  if  suppuration  is  acute  and  spreading,  the 
chances  of  recovery  are  not  great. 

pa 


GENERAL  AND  THERAPEUTIC  INDEX. 


Acetanalid,  103,  179 

Aciduin  carbolicum,  154,  155,  166, 

329 
Aciduin  gallicum,  308,  349 
Acidurn  muriaticum,  52,  329,  349 
Afidum  jiitricum,  160,  308,  349 
Aciduin  salic3'licuin,  352 
Acidum  tannicum,  161.  308 
Aconite,  48,  101,  214 
Alcoliol,  48,  103, 160, 213, 228, 278, 

290,  295 
Aloes,  158,  329 
Alpes,  147 

Ammonsemia,  263,  352 
Ammouii    aeetas,   130,    206,   271, 

291 
Ammonii  carbonas,43, 48,  85,  101, 

191,  206,  228 
Ammonii  citras,  271 
Ammonii  iodidum,  44 
Ammonii  murias,  16,  43 
Ammonii  salicylas,  269 
Amyloid  kidney,  263,  305,  337 

anatomy,  337 

causes,  337 

diagnosis,  340 

symptoms,  338 

treatment,  340 
Amylumnitritum.  263 
Anaemia,  40 

pernicious,  222 
Aneurism,  68,  215 
Angina  pectoris,  221,  227,  228 
Antimonii  et  potassii  tartras,  16, 

44,  50 
Auti pyrin,  47,  103,  154,  179 
Aortic  insufficiency,  243 
Aortic  stenosis,  245 
Apomorpliia,  50 
Argenti  nitras,  159 
Aspiration,  181,  191,  206,  311,  331, 

336 
Asthma,  3,  265 

causes,  10 

diagnosis,  9 

nature,  3 

symptoms,  4 

treatment,  11 


I  Atelectasis,  25,  67,  121 

anatomy,  67 
I      cause,  67 
symptoms,  68 
treatment,  69 
Atropia,  19,  102,  160,  349 
Aurei  et  sodil  chloridum,  109, 323 

Belladonna,  160,  360 
Bermudas,  149 

Blisters,  161,  179,  206,  209,  228 
Bromides,  15,  48,  261 
Bronchiectasis,  27,  36,  37,  57,  92, 
123 
anatomy,  57 
causes,  58 
symptoms,  58 
treatment,  59 
Bronchitis,  23,  75,  88,  241,  274 
acute,  22 
anatomy,  22 
symptoms,  28 
capillary,  68,  82,  85 
anatomy,  24 
sj'mptoms,  30 
chronic,  35,  57 
anatomy,  25 
symptoms,  33 
bronchorrhoea,  36 
dry,  36 
purulent,  36 
putrid,  37,  115 
causes,  39 
diagnosis,  38 
treatment,  42 

Caffeine,  206,  213,  222,  233,  308 

Calculus,  350 

California,  149 

Calomel,  101,  179,  206,  228,  327 

Camphor,  48,   85,   101,   191,   206, 

228 
Cantharides,  350 
Cardiac  dilatation,  68,  210 
Cascara  sagrada,  158,  329 
Charcot's  crystals,  8 
Chloral,  15,  43;  58,  154,  260,  272 
Chloroform,  15,  222,  260,  272,  349 

(355) 


356 


General  and  Therapeutic  Index. 


Chlorosis,  222 

Cocaine,  14 

Codeia,  48,  154,  179,  191     • 

Codliver-oil,  152,  186 

Colchicum,  51 

Colocyuth,  271 

Colorado  sprin2:s,  147 

Convallaria,  206,  213,  237,  331 

Copaiba,  54,  290,  350,  352 

Coronary  sclerosis,  227 

Creasote,  44,  54,  118,  155,  162 

Croton-oil,  271 

Cubebs,  278 

Cupping,  206,  209,  290,  352 

Cystitis,  350 

Diabetes,  42, 141 

Diarrhoea,  135,  332 

Digitalis,  15,  49,  74,  80,81,85,192, 
160,180,191,206,213,218, 
222,  237, 255, 260,  271,  277, 
291,294,325,330,331 

Diphtheria,  82 

Dover's  powder,  45,  100 

Eczema,  299 

Electricity,  260 

Elaterium,  271 

Embolism,  70,  323 

Emesis,  50 

Emphysema,  25,  29,  61,  82,  274 

anatomy,  61 

cause,  62 

symptoms,  63 

treatment,  67 
Empyema,  169,  177,  182,  171,  192 
Endarteritis  obliterans,  215 
Endocarditis,  98,  231,  312 

causes,  233 

chronic,  232 

malignant,  231 

prognosis,  238 

simple,  231 

symptoms,  234 

treatment,  237 

ulcerative,  231 
Ergot,  81,  102,  160,  161,  260,  308, 

349 
Erysipelas,  88 

Ether,  15,  228,  260,  272,  349 
Eucalyptus,  54,  118,  162* 

Florida,  149 
Fuchsin,  308 


Gelsemium,  154 

Gentian,  53, 158 

Georgia,  149 

Glucose,  292 

Gout,  295,  313 

Grindelia  robusta,  16 

Gymnastics,  respiratory,  110,  223 

Haematuria,  343 
Hav  fever,  10,  12 
Heart  dilatation,  210 

anatomy,  211 

cause,  210 

prognosis,  214 

symptoms,  211 

treatment,  212 
Heart,  fatty,  220 

anatomy,  220 

symptoms,  221 

treatment,  222 
Heart  hypertrophy,  215 

anatomy,  215 

cause,  215 

symptoms,  216 

treatment,  218 
Heart,     indurative    degeneration, 
226 

anatomy,  226 

symptoms,  227 

treatment,  228 
Hemoptysis,  71,  131,  136 
Hunyadi  Janos,  290,  327 
Hydj-argvri     chloridum     corrosi- 

vum,  311,  323 
Hydrargyri  subsulphas,  50 
HVdrothorax,  194,  201 

cause,  194 

diagnosis,  194 

prognosis,  195 

treatment,  195 
Hydronephrosis,  345 
Hydrops  pericardii,  207 
Hyoscyamus,  19,  260 

Ice-bag,  209,  228,  260 
Influenza,  82 
Ipecac,  50 

Iron,  65,  159,  213.  222,  230,  255, 
260,  293,  307,  331 

chloride,  tincture,  307 
Iron  citrate,  307 

potassio-tartrate,  307 

subcarbonate,  268,  307 

subsulphate,  161 


General  and  Therapeutic  Index. 


35T 


Jaborandi,  206,  269 

Kidney  congestion,  241,  263,  274, 
288 

cause,  274 

anatomy,  274 

symptoms,  276 

ti-eatment,  277 
Kidneys,  passive  congestion,  274 

anatomy,  274 

symptoms,  276 

treatment,  277 

Lactose,  292 

Laryngitis,  136 

Leeching,  206,  209,  290,  352 

Leukaemia,  222 

Lead  acetate,  349 

Liver  congestion,  241 

Lithium  acetate,  271 

benzoate,  269,  348 

citrate,  271 

carbonate,  325,  348 
Lithia  waters,  348 
Lobelia,  17 
Lung,  brown-induration,  75 

cause,  75 

symptoms,  76 
Lung  Hoemorrliagic  infarct,  70 

anatomy,  70 

cause,  70 

symptoms,  71 

treatment,  72 
Lung  hypostasis,  73 

causes,  73 

symptoms,  73 

treatment,  74 


Magnesium  sulphate,  290 

citrate,  180,  290 
Malaria,  295,  313,  363 
Manitou,  147 
Malt  extracts,  154,  156 
Measles,  82,  85 
Meningitis,  98 
Mitral  insufficiency,  246 

stenosis,  249 
Morphia,  14,  16,  46,  100,  154,  159, 

179,  191,  260,  272 
Myocarditis,  230 


Neoplasms  of  the  lungs. 
Nephrectomy,  336 


167 


Nephritis,  40 
diphtheritic,  263 
interstitial,  215,  263,   305,   313, 
340 
anatomy,  314 
causes,  313 
diagnosis,  323 

prognosis,  332  , 

symptoms,  318 
treatment,  323 
parenchymatous,  215 
acute,  215,  279,  263,  273,  277, 
305,  340 
anatomy,  280 
causes,  279 
diagnosis,  288 
prognosis,  294 
symptoms,  284 
treatment,  289 
chronic,  215, 263,  277, 281, 295, 
304,  340 
anatomy,  295 
causes,  295 
diagnosis,  305 
symptoms,  298 
treatment,  306 
scarlatinal,  263 
suppurative,  333,  344 
anatomy,  333 
causes,  333 
prognosis,  335 
symptoms,  334 
treatment,  336 
Nephrolithiasis,  342 
causes,  342 
symptoms,  342 
treatment,  347 
Nephrotomy,  336 
New  Mexico,  150 
New  York,  149 
Nitrites.  18,  218,  228,  312 
Nitro-glycerin,  17,  229 
Nux  vomica,  158 

Obesity,  222 

(Edema,  lungs,  73,  78,  241 

anatomy,  78 

causes,  79 

symptoms,  78 

treatment,  80 
Oleum  morrhuae,  53 
Opium,  15,  45,  100,  154,  159,  179, 

205,  209,  331,  352 
Oxygen,  81,  103,  223,  307,  331 


358 


General  and  Therapeutic  Index. 


Paregoric,  46,  155 
Pepsin,  52 
Pericarditis,  68,  98,  199 

anatomy,  199 

causes,  199 

symptoms,  199 

treatment,  205 
Pilocarpine,  20,  131,  269 
Pine-oil,  118,  155 
Plumbism,  313 
Plumbum  acetas,  159,  161 
Pleurisy,  58,  72,  98,  99,  123,  186, 
169,  194,  274,  304,  312 

anatomy,  169 

causes,  172 

diagnosis,  177 

prognosis,  186 

symptoms,  173 

treatment,  178 
Pneumatic  differentiation,  50,  66, 

69 
Pneumonia,  catarrhal,  25,  33,  82 

anatomy,  82 

causes,  82 

symptoms,  84 

treatment,  85 
Pneumonia,  croupous,  86,  73,  78, 
85,  115,  304,  312 

anatomy,  89 

causes,  86 

diagnosis,  99 

symptoms,  92 

treatment,  100 
Pneumonia  interstiatialis,  58,  107, 

274 
Pneumopericardium,  208 
Pneumothorax,  68,  187 

causes,  187 

diagnosis,  190 

prognosis,  193 

symptoms,  188 

treatment,  191 

varieties,  188 
Potassium   acetate,  180,  206.  271, 

291,  325,  348 
Potassium  chloride,  180  j 

Potassium   citrate,  271,   296,  325, 

348 

Potassium  iodide,  13,  44,  66,  100,  i 

180,230,311,323,330         j 

Potassium  nitrite,  329  I 

Pulmonary  abscess,  92,  112  j 

anatomy,  112 

causes,  112  ' 


Pulmonary  abscess,  diagnosis,  114 

symptoms,  113 
Pulmonary  cirrhosis,  107 

anatomy,  107 

causes,  109 

symptoms,  108 

treatment,  109 
Pulmonary  gangrene,  28,  92  114, 
138 

anatomy,  115 

causes,  114 

prognosis,  117 

symptoms,  116 

treatment,  117 
Pulmonary  tuberculosis,    82,    92, 
114,  120,  138 

anatomy,  120  , 

causes,  139 

diagnosis,  138 

prognosis,  165 

prophylaxis,  142 

symptoms,  129 

treatment,  145 
Pyaemia,  350 
Pyelitis,  343,  350 

anatomy,  350 

causes,  350 

diagnosis,  352 

prognosis,  353 

symptoms,  351 

treatment,  352 

Quebracho,  17 

Quinia,  45,  47,  65,  100,  102,  103, 
159,  213,  222,  293,  308, 331 

Renal  colic,  344 
Resorcin,  329,  352 
Retinitis  albuminurica,  321 
Rheumatism,  40,  88,  295 
Rochelle  salts,  270,  290 
Rocky  mountains,  147 
Rose  fever,  10 

Salol,  352 
San  Antonio,  150 
Sandalwood-oil,  352 
Sanguinaria,  46 
Scarlatina,  298.  313 
Senecio  aureus,  13,  17 
Sinapisms,  178,  260 
Small-pox,  350 
Sodium  acetate,  325 
benzoate,  269 


General  and  Therapeutic  Index. 


369 


Sodium  bicarbonate,  180 
bromide,  46 
chloride,  180 
citrate,  325 
iodide,  13,  44,  53,  66,  110,  180, 

230,  323,  330 
nitrite,  18,  229,  329 
salicylate,  51,  269 
tannate,  308 
Squills,  44,  46,  50,  290 
Stigmata  maiadis,  348 
Stramonium,  19 

Strophanthus,  49, 85, 102, 191, 206, 
213, 218, 222, 228, 255, 271, 
291,325,330,331 
Stryclinia,  45,  52,  65,  80,  81,  102, 
160,213,222,255,260,293, 
307,  331,  349 
Sulphuretted  hydrogen,  162 
Syphilis,  295,  306 

Tachycardia,  256 

causes,  258 

symptoms,  256 

treatment,  258 
Terpin  hydrate,  46 
Terrebene,  54 
Texas,  149 
Thoracentesis,  182 
Thrombus,  70,  274,  323 
Thymol,  162 
Trachitis,  22 

Tricuspid  insuflBciency,  251 
Tuberculin,  162 

Turpentine,  44,  54,  118,  155,  159, 
161,  278,  290,  350 


Typhoid,  73,  87,  94,  99,  350 

Uraemia,  263,  308,  323 

causes,  264 

diagnosis,  267 

prognosis,  273 

symptoms,  264 

treatment,  267 
Uraemic  amaurosis,  331 
Urethritis,  350 
Uva  ursa,  348 

Valerian,  260 

Valvular  diseases,  chronic,  239 

aortic  insufficiency,  243 
stenosis,  245 

combined  lesions,  253 

mitral  insufficiency,  246 
stenosis,  249 

nature  and  anatomy,  239 

prognosis,  254 

pulmonary,  250 

symptoms,  240 

treatment,  254 

tricuspid,  251 
Venesection,  81,  100 
Venice  turpentine,  44,  54 
Veratrum,  49,  101,  214 
Viburnum  prunifolium,  15 
Vichy  water,  348 
Vinegar,  160 

West  Indies,  149 
Whooping-cough,  42,  83,  85 

Zinci  oxidum,  160 


NOVEMBEB,  1892. 

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CLEVENGER — Spinal  Concussion.  Surgically  Consid- 
ered as  a  Cause  of  Spinal  Lijury,  and  Neurologi- 
cally  Restricted  to  a  Certain  Symptom  Group,  for 
which  is  Suggested  the  Designation  "  Hrichsen^s 
Disease,''''  as  One  Form  of  the  Traumatic  Neuroses. 

By  S.  V.  Clevenger,  M.D.,  Consulting  Physician,  Reese  and 
Alexian  Hospitals  ;  Late  Pathologist,  County  Insane  Asylum,  Chicago; 
Member  of   numerous   American  Scientific   and   Medical    Societies ; 


4  The  F.  A.  Davis  Co.,  Philadelphia,  Pa. 

Collaborator,  Alienist  and  Neurologist,  Journal  of  Neurology  and 
Ps3'chiatry,  Journal  of  Nervous  and  Mental  Diseases ;  Author  of 
■"  Comparative  Physiology  and  Psychology,"  etc. 

This  book  is  the  outcome  of  five  years'  special  study  and  experience 
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COLTMAN — The  Chinese :  Their  Present  and  Future ; 
Medical,  Political,  and  Social. 

By  Robert  Coltman,  Jr.,  M.D.,  Surgeon  in  Charge  of  the 
Presbyterian  Hospital  and  Dispensary  at  Teng  Chow  Fu ;  Consulting 
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DAVIS— Consumption :  How  to  Prevent  it  and  How  to 
Live  with  it.  Its  Nature,  Causes,  Pi^evention,  and 
the  Mode  of  Life,  Climate,  Exercise,  Food,  and 
Clothing  Necessary  for  its  Cure. 

By  N.  S.  Davis,  Jr.,  A.M.,  M.D,,  Professor  of  Principles  and 
Practice  of  Medicine,  Chicago  Medical  College ;  Physician  to  Mercy 
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DAVIS — Diseases  of  the  Lungs,  Heart,  and  Kidneys. 

By  N.  S.  Davis,  Jr.,  A.M.,  M.D.,  Professor  of  Principles  and 
Practice  of  Medicine,  Chicago  Medical  College ;  Physician  to  Mercy 
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DEMARQUAY — On  Oxygen.  A  Practical  Investigation 
of  the  Clinical  and  Therapeutic  Value  of  the 
Gases  in  Medical  and  Surgical  Practice,  with  Espe- 


The  F.  A.  Davis  Co.,  Philadelphia,  Pa.  5 

cial    Refe7'ence    to     the     Value     and    Availability 

of    Oxygen,    Nitrogen,    Hydrogen,   and    Niti^ogen 

Monoxide. 

By  J.  N.  Demarquat,  Surgeon  to  the  Municipal  Hospital,  Paris, 
and  of  the  Council  of  State  ;  Member  of  the  Imperial  Society  of  Sur- 
<rery,  etc.  Translated,  with  notes,  additions,  and  omissions,  by  Samuel 
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EDINGER — Twelve   Lectures  on  the  Structure  of  the 

Central    Nervous   System.      For    Physicians    and 

Students. 

By  Dr.  Ludwig  Edinger,  Frankfort-on-the-Main.  Second  Re- 
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sota; Member  of  the  American  Neurological  Association.  The  illus- 
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EISENBERG— Bacteriological  Diagnosis.    Tabular  Aids 
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By  James  Eisenberg,  Ph.D.,  M.D.,  Vienna.  Translated  and 
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GOODELL — Lessons  in  Gynaecology. 

By  William  Goodell,  A.M.,  M.D.,  etc..  Professor  of  Clinical 
Gynaecology  in  the  University  of  Pennsylvania.      With  112  illustra- 


6  The  F.  A.  Davis  Co.,  Philadelphia^  Pa. 

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GUERNSEY— Plain  Talks  on  Avoided  Subjects. 

By  Henrt  N.  Guernsey,  M.D.,  formerly  Professor  of  Materia 
Medica  and  Institutes  in  the  Hahnemann  Medical  College  of  Philadel- 
phia ;  Author  of  Guernsey's  "  Obstetrics,"  including  the  Disordera 
Peculiar  to  Women  and  Young  Children,  etc. 

Contexts  of  the  Book. — I.  Introductory.  II.  The  Infant.  III. 
Childhood.  IV.  Adolescence  of  the  Male.  V.  Adolescence  of  the 
Female.  VI.  Marriage  :  The  Husband.  VII.  The  Wife.  VIII.  Hus- 
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HARE — Epilepsy:  its  Pathology  and  Treatment.  Being 
an  Essay  to  which  was  Awarded  a  Prize  of  Four 
TJwusand  Francs  by  the  Academie  Royal  de  Mede- 
cine  de  Belgique,  December  31,  1889. 

By  HoBART  Amort  Hare,  M.D.,  B.Sc,  Professor  of  Materia 
Medica  and  Therapeutics  in  the  Jefferson  Medical  College,  Philadel- 
phia ;  Physician  to  St.  Agnes'  Hospital  and  to  the  Children's  Dispen- 
sary of  the  Children's  Hospital,  Philadelphia,  etc.  Laureate  of  the 
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HARE — Fever:  its  Pathology  and  Treatment.  Being 
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for  1890  ;  containing  Directions  and  the  Latest  In- 
formation Concerning  the  Use  of  the  So-Galled 
Antipyretics  in  Fever  and  Pain, 

By  HoBART  Amort  Hare,  M.D.,  B.Sc.  Illustrated  with  more 
than  25  new  plates  of  tracings  of  various  fever  cases,  showing  beauti- 
fully and  accurately  the  action  of  the  antipyretics.  The  work  also 
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HUIDEKOPER— Age  of  the  Domestic  Animals.  Being 
a  Complete  Treatise  on  the  Dentition  of  the  Horse. 
Ox^  Sheepj  Hog,  and  Dog,  and  on  the  Various  Other 
Means  of  Determining  the  Age  of  these  Animals. 

By  Rush  Shippen  Huidekoper,  M.D.,  Veterinarian  (Alfort, 
France)  ;  Professor  of  Sanitary  Medicine  and  Veterinary  Jurispru- 
dence, American  Veterinary  College,  New  York ;  Late  Dean  of  th€ 
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International  System  of  Electro-Therapeutics. 

Chief  editor,  Horatio  R.  Bigelow,  M.D.,  Permanent  Member  of 
the  American  Medical  Association ;  Fellow  of  the  British  Gyneco- 
logical Society  ;  Fellow  of  the  American  Electro-Therapeutic  Associa- 
tion ;  Member  of  the  Philadelphia  Obstetrical  Society  ;  Member  of  the 
Societe  Francaise  d'Electro-Therapte ;  Author  of  "  Gynaecological 
Electro-Therapeutics,"  and  "  Familiar  Talks  on  Electricity  and 
Batteries."  Assisted  by  upward  of  thirty  eminent  specialists  in 
Europe  and  America  as  associate  editors.  Thoroughly  illustrated  with 
many  fine  engravings.     Over  900  pages.     Royal  Octavo.     In  Press. 

IVINS — Text- Book  on  Diseases  of  the  Nose  and  Throat. 

By  Horace  F.  Ivins,  M.D.,  Lecturer  on  Laryngology  and  Otology 
in  Hahnemann  Medical  College  and  Hospital,  Philadelphia ;  Laryngo- 
logical  Editor  of  the  "Journal  of  Ophthalmology,  Otology,  and 
Laryngology,"  etc.,  etc.  Royal  Octavo,  about  500  pages.  Beautifully 
printed,  with  very  many  colored  plates  and  other  engravings.  Chiefly 
Original,  from  drawings  and  photographs  of  Anatomical  Dissections, 
etc.    In  Press.     Ready  in  the  Fall  of  1893. 

KEATING— Record- Book  of  Medical  Examinations  for 
Life-insurance. 

Designed  by  John  M.  Keating,  M.D.  This  record-book  is 
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required  by  the  different  companies.  It  is  made  in  two  sizes,  viz  ; 
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KEATING  AND  EDWARDS— Diseases  of  the  Heart 
and  Circulation  in  Infancy  and  Adolescence.  With 
an  Appendix  entitled  ""  Clinical  Studies  on  the 
Pulse  in  Childhood. 

By  John  M.  Keating,  M.D.,  formerly  Obstetrician  to  the  Phila- 
delphia Hospital  and  Lecturer  on  Diseases  of  Women  and  Children  ; 
Surgeon  to  the  Maternity  Hospital,  Philadelphia,  etc. ;  and  William 
A.  Edwards,  M.D.,  formerly  Instructor  in  Clinical  Medicine  and 
Physician  to  the  Medical  Dispensary  in  the  University  of  Pennsyl- 
vania, and  Assistant  Pathologist  to  the  Philadelphia  Hospital,  etc. 
Illustrated  by  Photographs  and  Wood-Engravings.  About  225  pages. 
8vo.     Bound  in  Cloth. 

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LIEBIG  AND  ROME— Practical  Electricity  in  Medicine 
and  Surgery. 

By  G.  A.  LiEBiG,  Jr.,  Ph.D.,  Assistant  in  Electricity,  Johns  Hop- 
kins University;  Lecturer  on  Medical  Electricity,  College  of  Physi- 
cians and  Surgeons,  Baltimore,  etc. ;  and  George  H.  Rohe,  M.D., 
Professor  of  Obstetrics  and  Hygiene,  College  of  Physicians  and  Sur- 
geons, Baltimore  ;  Visiting  Physician  to  Bay  View  and  City  Hospitals ; 
Director  of  the  Maryland  Maternity,  etc.  Profusely  Illustrated  by 
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MANTON— Childbed ;  its  Management;  Diseases  and 
theip  Treatment. 

By  Walter  P.  Manton,  M.D.,  Visiting  Physician  to  the  Detroit 
Woman's  Hospital ;  Consulting  Gynaecologist  to  the  Eastern  Michigan 
Asylum  ;  President  of  the  Detroit  Gynjecological  Society ;  FelloAv"  of 
the  American  Society  of  Obstetricians  and  Gynaecologists,  and  of  the 
British  Gynaecological  Society,  etc.  In  one  neat  12mo  volume.  In 
Preparation. 

MASSEY— Electricity  in  the  Diseases  of  Women.     With 

Special   Reference    to   the    Application   of    Strong 
Currents. 

By  G.  Betton  Masset,  M.D.,  Physician  to  the  Gynaecological 
Department  of  the  Howard  Hospital ;  Late  Electro-Therapeutist  to  the 
Philadelphia  Orthopaedic  Hospital  and  Infirmary  for  Nervous  Diseases ; 
Member  of  the  American  Neurological  Association,  etc.  Second 
Edition.  Revised  and  enlarged.  "With  New  and  Original  Wood- 
Engravings.  Handsomely  bound  in  Dark-Blue  Cloth.  240  pages. 
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MICHENER— Hand-Book  of  Eclampsia;  or,  Notes  and 
Cases  of  Puerperal  Convulsions. 

By  E.  MiCHENER,  M.D. ;  J.  H.  Stubbs,  M.D.  ;  R.  B.  Ewing, 
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MONTGOMERY— Practical  Gynaecology. 

By  E.  E.  Montgomery,  A.M.,  M.D.,  Professor  of  Clinical  Gynse- 
cologj'  in  the  Jefierson  Medical  College,  Philadelphia;  Obstetrician  to 
the  Philadelphia  Hospital ;  Gynaecologist  to  the  St.  Joseph  Hospital ; 
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and  Gynaecologists,  etc.,  etc.  In  one  handsome  Royal  Octavo  volume. 
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NISSEN— A  Manual  of  Instruction  for  Giving  Swedish 
Movement  and  Massage  Treatment. 

By  Prof.  Hartvig  Nissen,  late  Director  of  the  Swedish  Health 
Institute,  Washington,  D.  C. ;  lat«  Instructor  in  Physical  Culture  and 
Gymnastics  at  the  Johns  Hopkins  University,  Baltimore,  Md.  ;  In- 
structor of  Swedish  and  German  Gymnastics  at  Harvard  University's 
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Cloth. 

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NISSEN— A  B  C  of  the  Swedish  System  of  Educational 
Gymnastics.  A  Practical  Hand-Book  for  School- 
Teachers  and  the  Home. 

By  Hartvig  Nissex.  The  author  has  avoided  the  nse  of  diflScult 
scientific  terms,  and  made  it  as  popular  and  plain  as  possible.  The 
fullest  instructions  and  commands  are  given  for  each  exercise,  and 
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PACKARD— A  Practice  of  Surgery. 

By  John  H.  Packard,  A.M.,  M.D.^  Surgeon  to  the  Pennsylvania 
Hospital  and  to  St.  Joseph's  Hospital, "Philadelphia;  Member  of  the 
American  Surgical  Association  andiOf  the  American  Medical  Associa- 
tion;  formerly  Acting  Assistant  Surgeon  U.  S.  Army  (1861-65),  etc., 
etc.  In  one  large  Royal  Octavo  volume.  Handsomely  Illustrated. 
In  Preparation.  x  ^ 

Physicians'  AU-Requisite  Time-  and  Labor-  Saving 
Account-Book.  ..Being  a  Ledger  and  Account-Book 
for  Physician s\Use,  Meeting  all  the  Mequirements 
of  the  Law  and  Courts. 

Designed  by  William  A.  Seibert,  M.D.,  of  Easton,  Pa.  There 
Is  no  exaggeration  in  stating  that  this  Account-Book  and  Ledger  re- 
duces the  labor  of  keeping  your  accounts  more  than  one-half,  and  at 
the  same  time  secures  the  greatest  degree  of  accuracy. 

To  all  physicians  desiring  a  quick,  accurate,  and  comprehensive 
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address  on  application. 

Physicians'  Interpreter:  In  Four  Languages  {English, 
French,  German,  and  Italian). 

Specially  arranged  for  diagnosis  by  M.  von  V.  The  object  of  this 
little  work  is  to  meet  a  need  often  keenly  felt  by  the  busy  physician, 
namely,  the  need  of  some  quick  and  reliable  method  of  communicating 


The  F.  A.  Davis  Co.,  Philadelphia,  Pa.  11 

intelligibly  with  patients  of  those  nationalities  and  languages  un- 
familiar to  the  practitioner.  The  plan  of  the  book  is  a  systematic 
arrangement  of  questions  upon  the  various  branches  of  Practical 
Medicine,  and  each  question  is  so  worded  that  the  only  answer  required 
of  the  patient  is  merely  Yes  or  No.  The  questions  are  all  numbered, 
and  a  complete  Index  renders  them  always  available  for  quick  refer- 
ence. The  book  is  written  by  one  who  is  well-versed  in  English, 
French,  German,  and  Italian,  being  an  excellent  teacher  in  those  lan- 
guages, and  who  has  also  had  considerable  hospital  experience.  Bound 
in  full  Russia  Leather,  for  carrying  in  the  pocket.  Size,  5  x  2|  inches. 
206  pages. 

Price,  in  United  States  and  Canada,  post-paid,  i$1.0O,  net; 
Great  Britain,  6s. ;  France,  6  fr.  20. 

PRICE  AND  EAGLETON— Three  Charts  of  the  Nervo- 

Vasculap  System.     Part  I. —  The  Nerves.     Part  II, 

—  The  Arteries.     Part  III, —  The  Veins. 

A  New  edition,  Revised  and  Perfected.  Arranged  by  W.  Henry 
Price,  M.D.,  and  S.  Potts  Eagleton,  M.D.  Endorsed  by  leading 
Anatomists.  "The  Nervo-Vascular  System  of  Charts"  far  excels 
every  other  system  in  their  completeness,  compactness,  and  accuracy. 
Clearly  and  beautifully  printed  upon  extra-durable  paper.  Each  chart 
measures  19  x  24  inches. 

Price,  in  the  United  States  and  Canada,  post-paid,  50  cents,  net, 
Coni^lete ;  Great  Britain,  3s.  6d. ;  France,  3  fr.  60. 

PURDY— Diabetes:    its  C^use,  Symptoms,  and  Treat- 
ment. 

By  Chas;  W.  Purdy,  M.D.  (Queen's  University),  Honorary 
Fellow  of  the  Royal  College  of  Physicians  and  Surgeons  of  Kingston  ; 
Member  of  the  College  of  Physicians  and  Surgeons  of  Ontario  ;  Author 
of  ''  Bright's  Disease  and  Allied  Affections  of  the  Kidneys  ;  "  Member 
of  the  Association  of  American  Physicians  ;  Member  of  the  American 
Medical  Association  ;  Member  of  the  Chicago  Academy  of  Sciences, 
etc.,  etc.  With  Clinical  Illustrations.  In  one  neat  i2mo  volume. 
Handsomely  bound  in  Dark-Blue  Cloth.  No.  8  in  t?ie  Physicians'  and 
Students'  Beady- Reference  Series. 

Price,  United  States  and  Canada,  S1.25,  net ;  Great  Britain, 
6s.  6d. ;  France,  7  fr.  T5  ;  post-paid. 

PURDY — A  Systematic  Treatise    on    Diseases   of  the 
Urinary  arid  Renal  System. 

By  Cha^.  W.  PuRiyr,  M.D.  (Queen's  University),  Author  of 
"  Bright's  Diseases  and  Allied  Affections  of  the  Kidneys  ;"  "  Diabetes  : 
its  Causes,  Symptoms,  and  Treatment,"  etc.  In  four  handy  12mo 
volumes.    Bound  in  Extra  Cloth,  handsomely  illustrated  with  colored 


12  The  F.  A.  Davis  Co.,  Philadelphia^  Fa. 

plates  and  other  engravings.  Volume  I. — The  Urine ;  Normal  and 
Abnormal,  Chemically  and  Clinically  considered.  Volume  II.— Dis- 
eases of  the  Urinary  Passages.  Volumes  III  and  IV. — Diseases  of 
the  Kidneys. 

Volume  I  will  be  ready  early  in  1893.  Remaining  volumes  will 
follow  at  intervals  of  a  few  months  each. 

REMONDINO— History    of   Circumcision.      From    the 

Earliest  Times  to  the  Present.  Moral  and  Phys- 
ical Reasons  for  its  Performance ;  with  a  History 
of  Eunuchism^  Hermaphrodism^  etc.^  and  of  the 
Different  Operations  Practiced  upon  the  Prepuce, 

By  P.  C.  Remondino,  M.D.  (Jefferson),  Member  of  the  American 
Medical  Association ;  of  the  American  Public  Health  Association ; 
Vice-President  of  California  State  Medical  Society  and  of  Southern 
California  Medical  Society,  etc.  12mo,  346  pages.  Extra  Cloth. 
Illustrated  with  two  fine  full-page  wood-engravings,  showing  the  two 
principal  modes  of  Circumcision  in  ancient  times.  No.  11  in  the 
Physicians'  and  Students'  Ready-Reference  Senes. 

Price,  in  United  States  and  Canada,  post-paid,  S1.S5,  net; 

Great  Britain,  6s.  6d. ;  France,  7  fr.  75. 
A  Popular  Edition  (unabridged),  bound  in  Paper  Covers,  is 

also    issued.     Price,  50  cents,   net ;    Great  Britain,   3s. ; 

France,  3  fr.  60. 

REMONDINO — The  Mediterranean  Shores  of  America. 

Southern  California:  its  Climatic,  Physical,  and 
Meteorological   Conditions. 

By  P.  C.  Remonbino,  M.D.,  (Jefferson),  etc.  Complete  in  one 
handsomely  printed  Octavo  volume  of  nearly  175  pages,  with  45  ap- 
propriate illustrations  and  2  finely  executed  maps  of  the  region,  show- 
ing altitudes,  ocean  currents,  etc.     Bound  in  Extra  Cloth. 

Price,  in  United  States  and  Canada,  post-paid,  91.35,  net ; 

Great  Britain,  6s.  6d. ;  France,  7  fr.  75. 
Cbeaper  Edition  (unabridged),  bound  in  Paper,  in  United 

States   and    Canada,    post-paid,    75    Cents,    net;    Great 

Britain,  48. ;  France,  5  fr. 

ROHE — Text- Book  of  Hygiene.  A  Comprehensive 
Treatise  on  the  Principles  and  Practice  of  Pre- 
ventive Medicine  from  an  American  Stand-point. 

By  George  H.  Rohe,  M.D.,  Professor  of  Obstetrics  and  Hygiene 
in  the  College  of  Physicians  and  Surgeons,  Baltimore ;  Member  of 
the  American  Public  Health  Association,  etc.  Second  Edition, 
thoroughly  revised  and  largely  rewritten,  with  many  illustrations  and 
valuable  tables.     Royal  Octavo,  over  400  pages.     Extra  Cloth. 

Price,  United  States,  post-paid,  SS.50,  net;  Canada  (duty  paid), 
82.75,  net ;  Great  Britain,  14s. ;  France,  16  fr.  80. 


The  F.  A.  Davis  Co.,  Philadelphia,  Pa.  13 

ROME — A  Practical  Manual  of  Diseases  of  the  Skin. 

By  George  H.  Rohe,  M.D.,  assisted  by  J.  Williams  Lord, 
A.B.,  M.D.,  Lecturer  on  Dermatology  and  Bandaging  in  the  College 
of  Physicians  and  Surgeons ;  Assistant  Physician  to  the  Skin  De- 
partment in  the  Dispensary  of  Johns  Hopkins  Hospital.  12mo,  over 
300  pages,  bound  in  Extra  Dark-Blue  Cloth.  No.  IS  in  the  Phy- 
sicians' and  Stvdeiits'  Ready-Reference  Series. 

Price,  in  United  States  and  Canada,  post-paid,  SI. 25,  net; 
Great  Britain,  6s.  6d. ;  France,  7  fr.  75. 

The  PRACTICAL  character  of  this  work  makes  it  specially  desirable 
for  the  use  of  students  and  general  practitioners.  The  nearly  one 
hundred  (100)  reliable  and  carefully  prepared  Formulae  at  the  end  of 
the  volume  add  not  a  little  to  its  practical  value. 


SAJOUS— Hay  Fever  and  its  Successful  Treatment  by 
Superficial  Organic  Alteration  of  the  Nasal  Mucous 
Membrane. 

By  Charles  E.  Sajous,  M.D.,  formerly  Lecturer  on  Rhinology 
and  Laryngology  in  Jefferson  Medical  College  ;  Vice-President  of  the 
American  Laryngological  Association ;  OflBcer  of  the  Academy  of 
France  and  of  Public  Instruction  of  Venezuela  ;  Corresponding  Mem- 
ber of  the  Royal  Society  of  Belgium,  of  the  Medical  Society  of  Warsaw 
(Poland),  and  of  the  Society  of  Hygiene  of  France ;  Member  of  the 
American  Philosophical  Society,  etc.,  etc.  With  13  Engravings  on 
Wood.    12mo.     Bound  in  Cloth,     Beveled  edges. 

Price,   in   United   States   and   Canada,    $1.00,    net;    Great 
Britain,  6s.;  France,  6  fr.  20. 

SANNE— Diphtheria,  Croup:  Tracheotomy  and  Intuba- 
tion. 

From  the  French  of  A.  Sanne.  Translated  and  enlarged  by 
Henry  Z.  Gill,  M.D,,  LL.D.  Diphtheria  having  become  such  a 
prevalent,  wide-spread,  and  fatal  disease,  no  general  practitioner  can 
afford  to  be  without  this  work.  It  will  aid  in  preventive  measures, 
stimulate  promptness  in  the  application  of  and  efficiency  in  treatment, 
and  moderate  the  extravagant  views  which  have  been  entertained 
regarding  certain  specifics  in  the  disease  diphtheria. 

A  full  Index  accompanies  the  enlarged  volume,  also  a  list  of 
authors,  making,  altogether,  a  very  handsome  Illustrated  Royal 
Octavo  volume  of  over  680  pages. 

Price,  United  States,  post-paid,  Cloth,  S4.00  ;  I^eather,  S5.00. 
Canada  (duty  paid).  Cloth,  $4.40;  Lieather,  $5.50,  net. 
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Cloth,  34  fr.  60 ;  Leather,  30  fr.  30. 


14  Tlie  F.  A.  Davis  Co.,  Philadelphia,  Fa. 

SENN — Principles  of  Surgery. 

By  N.  Senx,  M.D.,  Ph.D.,  Professor  of  Principles  of  Surg:ery  and 
Surgical  Pathologj'  in  Rush  Medical  College,  Chicago,  111.  ;  Professor 
of  Surgery  in  the  Chicago  Polyclinic  ;  Attending  Surgeon  to  the  Mil- 
waukee Hospital ;  Consulting  Surgeon  to  the  Milwaukee  County  Hos- 
pital and  to  the  Milwaukee  County  Insane  Asylum.  Royal  Octavo, 
with  109  fine  Wood-Engravings,  624  pages. 

Price,  in  United  States,  Cloth,  $4.50  ;  Sheep  or  Half-Kassia, 
$5.50,  net.  Canada  (duty  paid),  Cloth,  $5.00;  Sheep  or 
Half-Kassia,  $6.10,  net.  Great  Britain,  Cloth,  34s.  6d.  ; 
Sheep  or  Half-Kussia,  30s.  France,  Cloth,  37  fr.  20; 
Sheep  or  Half-Kussia,  33  fr.  10. 

SENN— Tuberculosis  of  the  Bones  and  Joints. 

By  N.  Senn,  M.D.,  Ph.D.,  author  of  a  text-book  on  the  "  Prin- 
ciples of  Surgery,"  etc.,  etc.  In  one  handsome  Royal  Octavo  volume. 
Over  500  pages.  Illustrated  with  upwards  of  one  hundred  (100) 
engravings,  many  of  them  colored. 

Price,  in  United  States,  Extra  Cloth,  $4.00,  net ;  Sheep  or 
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$4.40,  net ;  Sheep  or  Half-Kussia,  $5.50,  net.  Great 
Britain,  Cloth,  33s.  6d. ;  Sheep  or  Half-Kussia,  38s. 
France,  Cloth,  34  fr.  60;  Sheep  or  Half-Kussia,  30 
fr.  30. 

SHOEMAKER— Heredity,  Health,  and  Personal  Beauty. 

Including  the  Selection  of  the  Best  Cosmetics  for 
the  Skin,  Hair,  Nails,  and  All  Parts  Relating  to  the 
Body. 

By  John  V.  Shoemaker,  A.M.,  M.D.,  Professor  of  Materia 
Medica,  Pharmacology,  Therapeutics,  and  Clinical  Medicine,  and 
Clinical  Professor  of  Diseases  of  the  Skin  in  the  Medico-Chirurgical 
College  of  Philadelphia ;  Physician  to  the  Medico-Chirurgical  Hos- 
pital, etc.,  etc.  This  is  jiist  the  book  to  place  on  the  waiting-room  table 
of  every  x>hysician,  and  a  vx)7'k  that  will  prove  xisefvl  in  the  hands  of  your 
patients. 

It  is  largely  suggestive,  and  gives  wise  and  timely  advice  as  to 
when  a  physician  should  be  consulted.  Royal  Octavo,  425  pages, 
Extra  Cloth,  Beveled  Edges,  with  side  and  back  gilt  stamps,  and  Half- 
Morocco  Gilt  Top. 

Price,  in  United  States,  post-paid.  Cloth,  $3.50,  net;  Half- 
Morocco,  $3.50,  net.  Canada  (duty  paid).  Cloth,  $3.75; 
Half-Morocco,  $3.90,  net.  Great  Britain,  Cloth,  14s.  ; 
Half-Morocco,  19s.  6d.  France,  Cloth,  15  fr. ;  Half- 
Morocco,  33  fr. 

SHOEMAKER— Materia  Medica  and  Therapeutics.  With 
Especial  Reference  to  the  Clinical  Application  of 
Drugs. 

Being  the  second  and  last  volume  of  a  treatise  on  Materia  Medica, 
Pharmacology,  and  Therapeutics,  and  an  independent  volume  upon 
drugs. 


The  F.  A.  Davis  Co.,  Philadelphia^  Pa.  15 

By  John  V.  Shoemaker,  A.M.,  M.D.,  Professor  of  Materia 
Medica,  Pharmacology,  Therapeutics,  and  Clinical  Medicine,  and 
Clinical  Professor  of  Diseases  of  the  Skin  in  the  Medico-Chirurgical 
College  of  Philadelphia ;  Physician  to  the  Medico-Chirurgical  Hos- 
pital, etc.,  etc. 

This  volume  is  wholly  taken  up  with  the  consideration  of  drugs, 
each  remedy  being  studied  from  three  points  of  view,  viz.  :  the  Prep- 
arations, or  Materia  Medica ;  the  Physiology  and  Toxicology,  or  Phar- 
macology ;  and,  lastly,  its  Therapy.  It  is  thoroughly  abreast  of  the 
progress  of  Therapeutic  Science,  and  is  really  an  indispensable  book  to 
evei-y  student  and  practitioner  of  medicine.  Royal  Octavo,  about  675 
pages.     Thoroughly  and  carefully  indexed. 

Price,  in  United  States,  post-paid,  Cloth,  S3.50 ;  Sheep,  $4.50, 
net.  Canada  (duty  paid).  Cloth,  $4.00;  Sheep,  $5.00, 
net.  Great  Britain,  Cloth,  19s.;  Sheep,  35s.  France, 
Cloth,  33  fr.  40 ;  Sheep,  3S  fr.  60. 

The  first  volume  of  this  work  is  devoted  to  Pharmacy,  General 
Pharmacology,  and  Therapeutics,  and  remedial  agents  not  properly 
classed  with  drugs.  Royal  Octavo,  353  pages.  Price  of  volume  I, 
post-paid,  in  United  States,  Cloth,  $2.50,  net;  Sheep,  $3.25,  net. 
Canada,  duty  paid,  Cloth,  $2.75,  net ;  Sheep,  $3.60,  net.  Great  Britain, 
Cloth,  14s.,  Sheep,  18s.  France,  Cloth,  16  fr.  30;  Sheep,  20  fr.  20. 
Tlie  vohmies  are  sold  separately. 


SHOEMAKER— Ointments    and   Oleates,   Especially  in 
Diseases  of  the  Skin. 

By  John  V.  Shoemaker,  A.M.,  M.D.  Second  Edition,  revised 
and  enlarged.  298  pages.  12mo.  Neatly  bound  in  Dark-Blue  Cloth. 
ITo.  6  in  the  Physicians'  and  Students'  Ready- Reference  Series. 

Price,  in  United  States  and  Canada,  post-paid,  S1.50,  net ; 
Great  Britain,  8s.  6d. ;  France,  9  fr.  35. 

The  author  concisely  concludes  his  preface  as  follows:  "The 
reader  may  thus  obtain  a  conspectus  of  the  whole  subject  of  inunction 
as  it  exists  to-day  in  the  civilized  world.  In  all  cases  the  mode  of 
preparation  is  given,  and  the  therapeutical  application  described 
seriatim,  in  so  far  as  may  be  done  without  needless  repetition." 


SMITH — The  Physiology  of  the  Domestic  Animals.    A 

Text-Book  for    Veterinary   and  Medical   Students 

and  Practitioners. 

By  Robert  Meade  Smith,  A.M.,  M.D.,  Professor  of  Comparative 
Physiology  in  University  of  Pennsylvania ;  Fellow  of  the  College  of 
Physicians  and  Academy  of  the  Natural  Sciences,  Philadelphia  ;  of  the 
American  Physiological  Society  ;  of  the  American  Society  of  Natural- 


16  The  F.  A.  Davis  Co.,  Philadelphia^  Pa. 

ists ;  Associ6  Etranger  de  la  Soci6t6  Francaise  d'Hygi^ne,  ete.  Royal 
Octavo,  over  950  pages.  Profusely  illustrated  with  more  than  400  fine 
Wood-Engravings,  some  of  them  Colored. 

Price,  in  United  States,  Cloth,  S5.00;  Sheep,  S6.00,  net. 
Canada  (duty  paid).  Cloth,  S5.50 ;  Sheep,  $6.60,  net. 
Great  Britain,  Cloth,  28s;  Sheep,  328.  France,  Cloth, 
30  fr.  30  ;  Sheep,  36  fr.  20. 

This  new  and  important  work  is  the  most  thoroughly  complete  in 
the  English  language  on  the  subject.  Without  being  overburdened 
with  details,  it  forms  a  complete  text-book  of  physiology,  adapted  to 
the  use  of  students  and  practitioners  of  both  veterinary  and  human 
medicine.  It  has  already  been  adopted  as  the  Text-Book  on  Physi- 
ology in  the  Veterinary  Colleges  of  the  United  States,  Great  Britain, 
and  Canada. 

SOZINSKEY — Medical  Symbolism.     Historical  Studies 
in  the  A7^ts  of  Healing  and  Hygiene. 

By  Thomas  S.  Sozinsket,  M.D.,  Ph.D.,  Author  of  "The 
Culture  of  Beauty,"  "  The  Care  and  Culture  of  Children,"  etc. 
13mo.  Nearly  200  pages.  Neatly  bound  in  Dark-Blue  Cloth.  Appro- 
priately illustrated  with  upward  of  thirty  (30)  new  Wood-Engravings. 
JVo.  9  in  t?ie  Physicians'  and  Students'  Beady-Heference  Series. 

Price,  in  United  States  and  Canada,  post-paid,  $1.00,  net; 
Great  Britain,  6s. ;  France,  6  £r.  20. 

STEWART — Obstetric  Synopsis.   A  Complete  Compend. 

By  John  S.  Stewart,  M.D.,  Demonstrator  of  Obstetrics  ami 
Chief  Assistant  in  the  Gynaecological  Clinic  of  the  Medico-Chirurgical 
College  of  Philadelphia ;  with  an  introductory  note  by  William  S. 
Stewart,  A.M.,  M.D.,  Professor  of  Obstetrics  and  Gynaecology  in  the 
Medico-Chirurgical  College  of  Philadelphia.  42  Illustrations.  202 
pages.  12mo.  Handsomely  bound  in  Dark-Blue  Cloth.  No.  1  in  the 
Physicians'  and  Students'  Beady-Refereme  Series. 

Price,  in  United  States  and  Canada,  post-paid,  Sl.OO,  net ; 
Great  Britain,  6s.  France,  6  fr.  20. 

ULTZMANN — The  Neuroses  of  the  Genito- Urinary  Sys- 
tem in  the  Male.      With  Sterility  and  Impotence. 

By  Dr.  Ultzmann,  Professor  of  Genito-Urinary  Diseases  in 
the  University  of  Vienna.  Translated,  with  the  author's  permission, 
by  Gardner  W.  Allen,  M.D.,  Surgeon  in  the  Genito-Urinary  De- 
partment, Boston  Dispensary.  Illustrated.  12mo.  Handsomely  bound 
In  Dark-Blue  Cloth.  No.  4  in  the  Physicians'  and  Students'  Beady- 
Befereixce  Series. 

Price,  in  United  States  and  Canada,  post-paid,  Sl.OO,  net ; 
Great  Britain,  6s.  ;  France,  6  fr.  20. 

Synopsis  of  Contents. — First  Part — I.  Chemical  Changes  in 
the  Urine  in  Cases  of  Neuroses.  II.  Neuroses  of  the  Urinary  and  of 
the  Sexual  Organs,  Classified  as  :  (1)  Sensory  Neuroses ;  (2)  Motor 
Neuroses  ;  (3)  Secretory  Neuroses.  Second  Part — Sterility  and  Im- 
potence.   The  treatment  in  all  cases  is  described  clearly  and  minutely. 


The  F.  A.  Davis  Co.,  Philadelphia,  Pa.  IT 

WITHERSTINE— International  Pocket  Medical  Formu- 
lary.    Arranged  Therapeutically. 

By  C.  Sumner  WiTHERSTiNE,  A.M.,  M.D.,  Associate  Editor  of  the 
"  Annual  of  the  Universal  Medical  Sciences  ;"  Visiting  Physician  of 
the  Home  for  the  Aged,  German  town,  Philadelphia ;  late  House  Sur- 
geon to  Charity  Hospital,  New  York.  Including  more  than  1800  for- 
mulae from  several  hundred  well-known  authorities.  With  an  Appendix 
containing  a  Posological  Table,  the  newer  remedies  included ;  Im- 
portant Incompatibles  ;  Tables  on  Dentition  and  Pulse  :  Table  of  Drops 
in  a  Fluidrachm  and  Doses  of  Laudanum  graduated  forage;  Formulae 
and  Doses  of  Hypodermatic  Medication,  including  the  newer  remedies  ; 
Uses  of  the  Hypodermatic  Syringe;  Formulae  and  Doses  for  Inhalations, 
Nasal  Douches,  Gargles,  and  Eye- Washes  ;  Formulae  for  Suppositories ; 
Use  of  the  Thermometer  in  Disease ;  Poisons,  Antidotes,  and  Treat- 
ment ;  Directions  for  Post-Mortem  and  Medico-Legal  Examinations ; 
Treatment  of  Asphyxia,  Sun-Stroke,  etc. ;  Anti-emetic  Remedies  and 
Disinfectants  ;  Obstetrical  Table  ;  Directions  for  Ligation  of  Arteries ; 
Urinary  Analysis  ;  Table  of  Eruptive  Fevers  ;  Motor  Points  for  Elec- 
trical Treatment,  etc.  This  work,  the  best  and  most  complete  of  its 
kind,  contains  about  275  printed  pages,  besides  extra  blank  leaves  for 
new  formulae.  Elegantly  printed,  with  red  lines,  edges,  and  borders, 
with  illustrations.     Bound  in  leather,  with  Side-Flap. 

Price,  in  iTnited  States  and.  Canada,  post-paid,  S3.00,  net; 
Great  Britain,  lis.  6d. ;  France,  12  fr.  40. 


YOUNG— Synopsis  of  Human  Anatomy.  Being  a  Com- 
plete Compend  of  Anatoimj,  including  the  Anatomy 
of  the  Viscera,  and  Numerous  Tables. 

By  James  K.  Young,  M.D.,  Instructor  in  Orthopaedic  Surgery 
and  Assistant  Demonstrator  of  Surgery,  University  of  Pennsylvania ; 
Attending  Orthopaedic  Surgeon,  Out-Patient  Department,  University 
Hospital,  etc.  Illustrated  with  76  Wood-Engravings.  320  pages. 
12mo.  Cloth.  iVb.  5  in  the  Physicians^  and  Student s^^Ready-Befermce 
Series. 

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\ 


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This  book  is  DUE  on  the  last  date  stamped  below. 


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